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Editorial Commentary: Hip Labral Reconstruction: A Necessary Skill for Hip Arthroscopy Surgeons

      Abstract

      The surgical treatment of labral deficiency has generated a tremendous amount of discussion and controversy among hip arthroscopists. The surgical reconstruction of the labrum has been viewed as the natural next step, after debridement and repair, in the advancement of our ability to treat patients with hip labral pathology. However, the indications for labral replacement and the profile of patients who would benefit from this complex intervention are still under debate. Every hip arthroscopist must have the technical ability to perform reconstruction when indicated. Repair or debridement does not always achieve best patient outcome.
      The treatment of hip labral pathology has seen a rapid transformation over the past 2 decades. As surgeons, we first moved from open treatment requiring surgical hip dislocation to the current gold standard of hip arthroscopy.
      • Botser I.B.
      • Smith Jr., T.W.
      • Nasser R.
      • Domb B.G.
      Open surgical dislocation versus arthroscopy for femoroacetabular impingement: A comparison of clinical outcomes.
      ,
      • Zhang D.
      • Chen L.
      • Wang G.
      Hip arthroscopy versus open surgical dislocation for femoroacetabular impingement: A systematic review and meta-analysis.
      From that stage, we came to recognize the importance of labral preservation with repair versus debridement.
      • Greaves L.L.
      • Gilbart M.K.
      • Yung A.C.
      • Kozlowski P.
      • Wilson D.R.
      Effect of acetabular labral tears, repair and resection on hip cartilage strain: A 7T MR study.
      • Larson C.M.
      • Giveans M.R.
      • Stone R.M.
      Arthroscopic debridement versus refixation of the acetabular labrum associated with femoroacetabular impingement: Mean 3.5-year follow-up.
      • 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.
      • Woyski D.
      • Mather 3rd, R.C.
      Surgical treatment of labral tears: Debridement, repair, reconstruction.
      • Riff A.J.
      • Kunze K.N.
      • Movassaghi K.
      • et al.
      Systematic review of hip arthroscopy for femoroacetabular impingement: The importance of labral repair and capsular closure.
      A large part of that recognition has come from our biomechanical understanding of the role of the labrum with regard to joint seal and fluid pressurization.
      • Dwyer M.K.
      • Jones H.L.
      • Hogan M.G.
      • Field R.E.
      • McCarthy J.C.
      • Noble P.C.
      The acetabular labrum regulates fluid circulation of the hip joint during functional activities.
      • Ferguson S.J.
      • Bryant J.T.
      • Ganz R.
      • Ito K.
      An in vitro investigation of the acetabular labral seal in hip joint mechanics.
      • Nepple J.J.
      • Philippon M.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.
      • Philippon M.J.
      • Nepple J.J.
      • Campbell K.J.
      • et al.
      The hip fluid seal—Part I: The effect of an acetabular labral tear, repair, resection, and reconstruction on hip fluid pressurization.
      Concurrent with this evolution in treatment techniques, there has been an increase in the number of hip arthroscopies performed for labral tears, with 1 study showing a quadrupled rate per 100,000 patients in less than a decade in the United States.
      • Colvin A.C.
      • Harrast J.
      • Harner C.
      Trends in hip arthroscopy.
      • Montgomery S.R.
      • Ngo S.S.
      • Hobson T.
      • et al.
      Trends and demographics in hip arthroscopy in the United States.
      • Maradit Kremers H.
      • Schilz S.R.
      • Van Houten H.K.
      • et al.
      Trends in utilization and outcomes of hip arthroscopy in the United States between 2005 and 2013.
      With a rate of revision hip arthroscopy after arthroscopic repair reported to be from 2.5% to 6.3%, the reality is that arthroscopic hip surgeons will be facing a growing burden of revision cases.
      • Harris J.D.
      • McCormick F.M.
      • Abrams G.D.
      • et al.
      Complications and reoperations during and after hip arthroscopy: A systematic review of 92 studies and more than 6,000 patients.
      • Nho S.J.
      • Beck E.C.
      • Nwachukwu B.U.
      • et al.
      Survivorship and outcome of hip arthroscopy for femoroacetabular impingement syndrome performed with modern surgical techniques.
      • Malviya A.
      • Raza A.
      • Jameson S.
      • James P.
      • Reed M.R.
      • Partington P.F.
      Complications and survival analyses of hip arthroscopies performed in the national health service in England: A review of 6,395 cases.
      Labral reconstruction has been shown to be an important weapon in our armamentarium for patients in those revision settings that have inadequate labral tissue remaining.
      • Ayeni O.R.
      • Adamich J.
      • Farrokhyar F.
      • et al.
      Surgical management of labral tears during femoroacetabular impingement surgery: A systematic review.
      • Ayeni O.R.
      • Alradwan H.
      • de Sa D.
      • Philippon M.J.
      The hip labrum reconstruction: Indications and outcomes--a systematic review.
      • 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.
      It is of great importance that we continue to better define when labral reconstruction is indicated and determine what reconstruction is best in the long term for our patients from a biomechanical perspective.
      I read the article by Suppaksorn, Beck, Chahla, Cancienne, Krivicich, Rasio, Shewman, and Nho, entitled “Comparison of Suction Seal and Contact Pressures Between 270 Degree Labral Reconstruction, Labral Repair, and the Intact Labrum,” with significant interest.
      • Suppauksorn S.
      • Beck E.C.
      • Chahla J.
      • et al.
      Comparison of suction seal and contact pressures between 270 degree labral reconstruction, labral repair, and the intact labrum.
      This was a cadaveric biomechanical study of 8 hemipelvis specimens that underwent electromechanical testing. The primary objective was to biomechanically compare the suction seal, contact area, contact pressures, and peak forces of 1) intact labrum, 2) labral tear, 3) labral repair between 12 and 3 o’clock, and 4) 270° labral reconstruction using iliotibial band (IBA) allograft. Although it is a cadaveric study with limited direct clinical translation, the authors have given us a valuable biomechanical study showing that a 270° labral reconstruction does not restore the suction seal and decreases the intraarticular contact area compared with a labral repair. This study builds on the foundation from earlier cadaveric studies, which documented the effect of a disrupted labrum on the force required to break the hip seal.
      • Nepple J.J.
      • Philippon M.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.
      The suction seal has been shown to regulate synovial fluid circulation, which is important for joint health.
      • Philippon M.J.
      • Nepple J.J.
      • Campbell K.J.
      • et al.
      The hip fluid seal—Part I: The effect of an acetabular labral tear, repair, resection, and reconstruction on hip fluid pressurization.
      These results do raise a concern, at least from biomechanical perspective, that a 270° labral reconstruction does not recreate the suction seal.
      The authors discuss how their study might apply to the heavily debated topic of whether labral reconstruction should be indicated in the primary setting or reserved only for revision cases. Some surgeons have advocated for primary reconstruction and have published results to support that approach,
      • White B.J.
      • Patterson J.
      • Herzog M.M.
      Bilateral hip arthroscopy: Direct comparison of primary acetabular labral repair and primary acetabular labral reconstruction.
      • White B.J.
      • Herzog M.M.
      Labral reconstruction: When to perform and how.
      • White B.J.
      • Stapleford A.B.
      • Hawkes T.K.
      • Finger M.J.
      • Herzog M.M.
      Allograft use in arthroscopic labral reconstruction of the hip with front-to-back fixation technique: Minimum 2-year follow-up.
      whereas other studies have showed lower outcome scores for reconstruction but a statistical equivalence to repair.
      • Chandrasekaran S.
      • Darwish N.
      • Mu B.H.
      • et al.
      Arthroscopic reconstruction of the irreparable acetabular labrum: A match-controlled study.
      ,
      • Scanaliato J.P.
      • Christensen D.L.
      • Salfiti C.
      • Herzog M.M.
      • Wolff A.B.
      Primary circumferential acetabular labral reconstruction: Achieving outcomes similar to primary labral repair despite more challenging patient characteristics.
      Whether one believes in primary reconstruction or not, in my opinion, this study highlights the importance of the native labrum and the challenges we face with reconstructing it. From my perspective, intraoperative management of labral tissue from joint entry to preparation for pincer resection is extremely important and, if done poorly, can have long-term negative consequences for a patient. It is in these primary cases that viability of the native labrum rests in the hands of the surgeon. However, there are instances in which a patient’s labrum simply is not salvageable and reconstruction is needed. It is paramount that as hip arthroscopists, we can recognize the differences and act accordingly.
      Hip arthroscopy is a highly technical procedure and is often referred to as having a steep learning curve.
      • Sampson T.G.
      Complications of hip arthroscopy.
      • Konan S.
      • Rhee S.J.
      • Haddad F.S.
      Hip arthroscopy: Analysis of a single surgeon’s learning experience.
      • Hoppe D.J.
      • de Sa D.
      • Simunovic N.
      • et al.
      The learning curve for hip arthroscopy: A systematic review.
      By increasing early exposure to hip arthroscopy during residency programs, and by expanding the number of fellowships available that offer significant hip arthroscopy experiences, I believe we will improve training and surgical outcome in hip arthroscopy. As individual surgeons already in practice, it is our responsibility to continue to advance our technical skill so that we can comprehensively care for our patients. Labral reconstruction is an essential skill for hip arthroscopists, and we need to continue to improve it.

      Supplementary Data

      References

        • Botser I.B.
        • Smith Jr., T.W.
        • Nasser R.
        • Domb B.G.
        Open surgical dislocation versus arthroscopy for femoroacetabular impingement: A comparison of clinical outcomes.
        Arthroscopy. 2011; 27: 270-278
        • Zhang D.
        • Chen L.
        • Wang G.
        Hip arthroscopy versus open surgical dislocation for femoroacetabular impingement: A systematic review and meta-analysis.
        Medicine. 2016; 95: e5122
        • Greaves L.L.
        • Gilbart M.K.
        • Yung A.C.
        • Kozlowski P.
        • Wilson D.R.
        Effect of acetabular labral tears, repair and resection on hip cartilage strain: A 7T MR study.
        J Biomech. 2010; 43: 858-863
        • Larson C.M.
        • Giveans M.R.
        • Stone R.M.
        Arthroscopic debridement versus refixation of the acetabular labrum associated with femoroacetabular impingement: Mean 3.5-year follow-up.
        Am J Sports Med. 2012; 40: 1015-1021
        • 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
        • Woyski D.
        • Mather 3rd, R.C.
        Surgical treatment of labral tears: Debridement, repair, reconstruction.
        Curr Rev Musculoskelet Med. 2019; 12: 291-299
        • Riff A.J.
        • Kunze K.N.
        • Movassaghi K.
        • et al.
        Systematic review of hip arthroscopy for femoroacetabular impingement: The importance of labral repair and capsular closure.
        Arthroscopy. 2019; 35: 646-656.e643
        • Dwyer M.K.
        • Jones H.L.
        • Hogan M.G.
        • Field R.E.
        • McCarthy J.C.
        • Noble P.C.
        The acetabular labrum regulates fluid circulation of the hip joint during functional activities.
        Am J Sports Med. 2014; 42: 812-819
        • 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
        • Nepple J.J.
        • Philippon M.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
        • Philippon M.J.
        • Nepple J.J.
        • Campbell K.J.
        • et al.
        The hip fluid seal—Part I: The effect of an acetabular labral tear, repair, resection, and reconstruction on hip fluid pressurization.
        Knee Surg Sports Traumatol Arthrosc. 2014; 22: 722-729
        • Colvin A.C.
        • Harrast J.
        • Harner C.
        Trends in hip arthroscopy.
        J Bone Joint Surg Am. 2012; 94: e23
        • Montgomery S.R.
        • Ngo S.S.
        • Hobson T.
        • et al.
        Trends and demographics in hip arthroscopy in the United States.
        Arthroscopy. 2013; 29: 661-665
        • Maradit Kremers H.
        • Schilz S.R.
        • Van Houten H.K.
        • et al.
        Trends in utilization and outcomes of hip arthroscopy in the United States between 2005 and 2013.
        J Arthroplasty. 2017; 32: 750-755
        • Harris J.D.
        • McCormick F.M.
        • Abrams G.D.
        • et al.
        Complications and reoperations during and after hip arthroscopy: A systematic review of 92 studies and more than 6,000 patients.
        Arthroscopy. 2013; 29: 589-595
        • Nho S.J.
        • Beck E.C.
        • Nwachukwu B.U.
        • et al.
        Survivorship and outcome of hip arthroscopy for femoroacetabular impingement syndrome performed with modern surgical techniques.
        Am J Sports Med. 2019; 47: 1662-1669
        • Malviya A.
        • Raza A.
        • Jameson S.
        • James P.
        • Reed M.R.
        • Partington P.F.
        Complications and survival analyses of hip arthroscopies performed in the national health service in England: A review of 6,395 cases.
        Arthroscopy. 2015; 31: 836-842
        • Ayeni O.R.
        • Adamich J.
        • Farrokhyar F.
        • et al.
        Surgical management of labral tears during femoroacetabular impingement surgery: A systematic review.
        Knee Surg Sports Traumatol Arthrosc. 2014; 22: 756-762
        • Ayeni O.R.
        • Alradwan H.
        • de Sa D.
        • Philippon M.J.
        The hip labrum reconstruction: Indications and outcomes--a systematic review.
        Knee Surg Sports Traumatol Arthrosc. 2014; 22: 737-743
        • 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
        • Suppauksorn S.
        • Beck E.C.
        • Chahla J.
        • et al.
        Comparison of suction seal and contact pressures between 270 degree labral reconstruction, labral repair, and the intact labrum.
        Arthroscopy. 2020; 36: 2433-2442
        • White B.J.
        • Patterson J.
        • Herzog M.M.
        Bilateral hip arthroscopy: Direct comparison of primary acetabular labral repair and primary acetabular labral reconstruction.
        Arthroscopy. 2018; 34: 433-440
        • White B.J.
        • Herzog M.M.
        Labral reconstruction: When to perform and how.
        Front Surg. 2015; 2: 27
        • White B.J.
        • Stapleford A.B.
        • Hawkes T.K.
        • Finger M.J.
        • Herzog M.M.
        Allograft use in arthroscopic labral reconstruction of the hip with front-to-back fixation technique: Minimum 2-year follow-up.
        Arthroscopy. 2016; 32: 26-32
        • Chandrasekaran S.
        • Darwish N.
        • Mu B.H.
        • et al.
        Arthroscopic reconstruction of the irreparable acetabular labrum: A match-controlled study.
        Arthroscopy. 2019; 35: 480-488
        • Scanaliato J.P.
        • Christensen D.L.
        • Salfiti C.
        • Herzog M.M.
        • Wolff A.B.
        Primary circumferential acetabular labral reconstruction: Achieving outcomes similar to primary labral repair despite more challenging patient characteristics.
        Am J Sports Med. 2018; 46: 2079-2088
        • Sampson T.G.
        Complications of hip arthroscopy.
        Clin Sports Med. 2001; 20: 831-835
        • Konan S.
        • Rhee S.J.
        • Haddad F.S.
        Hip arthroscopy: Analysis of a single surgeon’s learning experience.
        J Bone Joint Surg Am. 2011; 93: 52-56
        • Hoppe D.J.
        • de Sa D.
        • Simunovic N.
        • et al.
        The learning curve for hip arthroscopy: A systematic review.
        Arthroscopy. 2014; 30: 389-397