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Labral Degeneration Predicts Inferior Mid-Term Outcomes in Hip Labral Repair: A Multicenter Comparative Analysis

Published:February 27, 2022DOI:https://doi.org/10.1016/j.arthro.2022.02.019

      Purpose

      To analyze and compare the mid-term outcomes of hip arthroscopy for patients with and without labral degeneration from multiple orthopaedic centers. The purpose of this research is to develop an understanding of the impacts of labral degeneration on patient outcomes following arthroscopic treatment of labral tears.

      Methods

      A prospective multicenter hip arthroscopy registry was queried for primary surgeries from January 2014 to October 2017 with completed 2-year International Hip Outcome Tool-12 (iHOT-12) reports. Patients were placed into cohorts based on the presence or absence of labral degeneration noted intraoperatively during hip arthroscopy. Degeneration was defined as yellowing, ossification, or calcification present in at least 50% of the labrum. Differences in baseline variation between groups were assessed with a Wilcoxon rank-sum test or χ2 test. Two-year outcomes were assessed with iHOT-12. Multivariate logistic regression models were fitted while controlling for age, body mass index, sex, and preoperative iHOT-12 scores to identify significant predictors of achieving the clinically significant thresholds of minimal clinically important difference, substantial clinical benefit, and patient-acceptable symptom scale.

      Results

      In total, 735 patients met inclusion criteria, of whom 613 had complete outcomes information. Relative to the control group, the labral degeneration group was significantly older (mean age 44 ± 11 years vs 33 ± 12 years; P < .01). Both groups experienced statistically significant improvement in iHOT-12 scores from baseline to final follow-up (P < .001); however, patients with labral degeneration reported inferior 2-year iHOT-12 scores when compared with patients without degeneration (P < .001). In the logistic regression models, labral degeneration was a significant negative predictor of achieving iHOT-12 minimal clinically important difference (odds ratio [OR] 0.47; 95% confidence interval [95% CI] 0.28-0.79), patient acceptable symptom state (OR 0.50; 95 CI 0.32-0.77), and substantial clinical benefit (OR 0.58; 95% CI 0.37-0.89).

      Conclusions

      The results of our study conclude that patients with nondegenerative labral tissue at the time of repair have superior patient-reported outcomes at mid-term follow-up. The presence of labral degeneration was a negative predictor of achieving clinically significant thresholds after controlling for patient age, body mass index, sex, and baseline iHOT-12 scores.

      Level of Evidence

      III, retrospective comparative prognostic trial.
      The hip acetabular labrum plays important anatomical and biomechanical roles in the proper functioning of the hip joint,
      • Bsat S.
      • Frei H.
      • Beaulé P.E.
      The acetabular labrum: a review of its function.
      and hip labral pathology is a common cause of hip pain. Labral pathology resulting in pain has commonly been attributed to tearing,
      • Su T.
      • Chen G.X.
      • Yang L.
      Diagnosis and treatment of labral tear.
      but other factors, such as degeneration, also may affect outcomes.
      • Domzalski M.E.
      • Synder M.
      • Karauda A.
      • Papierz W.
      Histological changes of the acetabular labrum in coxarthrosis: Labral degeneration and repair.
      These factors are less well understood.
      Labral degeneration is defined as calcification and breakdown of the labral fibrocartilage,
      • Kawamura Y.
      • Tetsunaga T.
      • Yamada K.
      • et al.
      Mechanical stretching induces calcification and cartilage matrix metabolism, causing degeneration of the acetabular labrum.
      which has been characterized as a strongly calcifying tissue type.
      • Hawellek T.
      • Hubert J.
      • Hischke S.
      • et al.
      Calcification of the acetabular labrum of the hip: Prevalence in the general population and relation to hip articular cartilage and fibrocartilage degeneration.
      Degenerated labral tissue often presents as calcified or ossified tissue with yellowish discoloration.
      • Beck E.C.
      • Kunze K.N.
      • Friel N.A.
      • et al.
      Is there a correlation between outcomes after hip arthroscopy for femoroacetabular impingement syndrome and patient cortical bone thickness?.
      Degeneration of the labral tissue is a pathology most common in older patients and patients undergoing revision hip-preservation surgeries.
      • Domzalski M.E.
      • Synder M.
      • Karauda A.
      • Papierz W.
      Histological changes of the acetabular labrum in coxarthrosis: Labral degeneration and repair.
      ,
      • Gwathmey F.W.
      • Jones K.S.
      • Thomas Byrd J.W.
      Revision hip arthroscopy: Findings and outcomes.
      With respect to the etiology of labral tears, labral degeneration has been cited as a cause.
      • Su T.
      • Chen G.X.
      • Yang L.
      Diagnosis and treatment of labral tear.
      The presence of severe degeneration of the acetabular labrum may influence intraoperative decision-making, as labrums with severe degeneration may not be suitable candidates for labral repair.
      • Nakashima H.
      • Tsukamoto M.
      • Ohnishi Y.
      • et al.
      Clinical and radiographic predictors for unsalvageable labral tear at the time of initial hip arthroscopic management for femoroacetabular impingement.
      While labral degeneration has been associated with increased pain and lower hip function preoperatively,
      • Hubert J.
      • Hawellek T.
      • Moe M.
      • et al.
      Labral calcification in end-stage osteoarthritis of the hip correlates with pain and clinical function.
      the postoperative outcomes of patients who present with labral degeneration are not well-documented in the literature. Most analyses of patients with labral degeneration focus on the outcomes of labral reconstruction rather than repair.
      • Carreira D.S.
      • Kruchten M.C.
      • Emmons B.R.
      • Martin R.L.
      Arthroscopic labral reconstruction using fascia lata allograft: Shuttle technique and minimum two-year results.
      • 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.
      • Safran N.
      • Rath E.
      • Haviv B.
      • Atzmon R.
      • Amar E.
      The efficacy of labral reconstruction: A systematic review.
      Other analyses have only focused on the outcomes of labral degeneration in the setting of osteoarthritis.
      • Trisolino G.
      • Favero M.
      • Dallari D.
      • et al.
      Labral calcification plays a key role in hip pain and symptoms in femoroacetabular impingement.
      In particular, the mid-term outcomes of patients without arthritis who present with labral degeneration and are treated with arthroscopic labral repair are unknown. Analyzing mid-term outcomes are useful in that they permit time for patients to fully complete their surgical recovery.
      The goal of this study is to analyze and compare the mid-term outcomes of hip arthroscopy for patients with and without labral degeneration from multiple orthopaedic centers. The purpose of this research is to develop an understanding of the impacts of labral degeneration on patient outcomes following arthroscopic treatment of labral tears. It was hypothesized that patients who present with labral degeneration at the time of labral repair will report inferior outcome scores at the 2-year follow-up than patients who do not present with significant labral degeneration.

      Methods

      Our multicenter hip arthroscopy study group established a registry where patients undergoing labral repair were prospectively enrolled by 5 high-volume, board-certified, fellowship-trained surgeons in different areas of the United States. Enrollment in the registry occurred between January 2014 and October 2017. Informed consent was obtained from each patient before enrollment in the registry. The collection and storage of data was granted according to institutional requirements, and institutional review board approval (Piedmont Healthcare institutional review board, Atlanta, GA ) was granted to review the deidentified data registry. Patient-reported outcomes were collected via online surveys sent out 2 years after the date of surgery, and the surveys were live for a 3-month window after activation. Data from the registry were analyzed retrospectively after the formulation of the present study’s hypothesis.
      Inclusion criteria were patients undergoing primary arthroscopic labral repair for the pathology of a labral tear. Exclusion criteria were a Tönnis grade of 2 or greater, patients without a complete record of preoperative information, intraoperative information, and postoperative radiographic angles, or patients with less than 2-year outcome data. Preoperative information included patient demographics, comorbidities, symptoms, and preoperative diagnoses. Intraoperative information included the number of implants used for labral repair and intra-articular pathologies such as labral tearing, cartilage damage, and labral degeneration. Patients were not excluded based on the etiology of their injury (acute traumatic vs chronic degenerative) or their age. Data from patients with documented 2-year outcomes were reviewed, including the presence of labral degeneration at the time of hip arthroscopy.
      Hips with labral degeneration, defined as calcification, ossification, and/or yellowish discoloration of at least 50 percent of the labral substance at any segment upon visual inspection and/or probing, were included in the labral degeneration group. Hips that exhibited yellowing, ossification, or calcification in less than 50% of the labral tissue were included in the mild or no degeneration group. The presence or absence of degeneration was recorded immediately following the arthroscopic procedure. The cutoff of 50% was decided upon by the coinvestigators before data collection. Labral degeneration was classified at the discretion of the participating surgeon at the time of arthroscopy.
      The presence of acetabular cartilage damage also was noted intraoperatively and was classified according to the Beck scale of severity, with grade I classified as minimal cartilage loss with slight chondromalacia, grade II classified as debonding from the subchondral bone, grade III classified as cartilage cleavage and thinning, and grade IV classified as full-thickness cartilage loss on the acetabular rim.
      • Cameron M.L.
      • Briggs K.K.
      • Steadman J.R.
      Reproducibility and reliability of the Outerbridge classification for grading chondral lesions of the knee arthroscopically.
      Similar to the classifications for labral degeneration, all of the participating surgeons agreed before patient enrollment on the qualifications for each grade of severity to improve interrater reliability.
      The International Hip Outcome Tool from 2012 (iHOT-12), a validated measure of health-related quality of life,
      • Griffin D.R.
      • Parsons N.
      • Mohtadi N.G.
      • Safran M.R.
      Multicenter Arthroscopy of the Hip Outcomes Research Network. A short version of the International Hip Outcome Tool (iHOT-12) for use in routine clinical practice.
      was administered preoperatively and postoperatively via an electronic survey. Greater iHOT-12 scores correspond with a greater quality of life. iHOT-12 scores were compared between the 2 groups preoperatively and at a 2-year follow-up. Within the iHOT-12 score, the proportion of patients in each group who met the validated clinically significant thresholds of minimal clinically important difference (MCID), substantial clinical benefit (SCB), patient-acceptable symptom scale (PASS), and maximal outcome improvement were individually analyzed.
      • Martin R.L.
      • Kivlan B.R.
      • Christoforetti J.J.
      • et al.
      Minimal clinically important difference and substantial clinical benefit values for the 12-Item International Hip Outcome Tool.
      • Kivlan B.R.
      • Martin R.L.
      • Christoforetti J.J.
      • et al.
      The patient acceptable symptomatic state of the 12-Item International Hip Outcome Tool at 1-year follow-up of hip-preservation surgery.
      • Robinson P.G.
      • Maempel J.F.
      • Rankin C.S.
      • Gaston P.
      • Hamilton D.F.
      Evaluation of the patient acceptable symptom state following hip arthroscopy using the 12 item international hip outcome tool.
      • Maldonado D.R.
      • Kyin C.
      • Shapira J.
      • et al.
      Defining the maximum outcome improvement of the Modified Harris Hip Score, the nonarthritic hip score, the visual analog scale for pain, and the International Hip Outcome Tool-12 in the arthroscopic management for femoroacetabular impingement syndrome and labral tear.
      Differences in baseline variation in iHOT-12 scores between groups were assessed with a Wilcoxon rank-sum test or χ2 test. Multivariate logistic regression models were fitted while controlling for age, body mass index (BMI), sex, and preoperative iHOT-12 scores to identify significant predictors of achieving clinical thresholds.

      Results

      In total, 794 hip arthroscopies were documented among the 5 centers from 2014 to 2017. Among those, 59 were revision surgeries and were excluded from the cohorts; 122 patients were excluded because of incomplete 2-year follow-up reports. Complete 2-year outcomes information was recorded for 613 patients who met the inclusion criteria. The flow chart presented in Figure 1 outlines the processes of inclusion and stratification.
      Figure thumbnail gr1
      Fig 1Subject inclusion criteria and experimental groups.
      Of the 613 patients who underwent arthroscopic primary labral repair, 140 patients had labral degeneration and 473 did not have substantial labral degeneration as identified intraoperatively. A post hoc power analysis was performed for a power of 0.8 and alpha of 0.05 to determine that a sample size of 200, with 100 patients in each group, was necessary to achieve the desired statistical power for analysis. Analysis of baseline variation found that patients with substantial labral degeneration were more likely to be older (P < .001) and reported lower preoperative iHOT-12 scores (P = .037). Both groups reported significant improvement in iHOT-12 scores from baseline to 2-year follow-up with the no-degeneration cohort improving from 37 ± 19 to 76 ± 23 and the degeneration group improving from 33 ± 17 to 66 ± 27 on iHOT-12 (P < .001). Both of these mean improvements met MCID. While still improving from baseline, the labral degeneration group exhibited significantly lower iHOT-12 scores at 2-year follow-up than the control group (76 ± 23 vs 66 ± 27, P < .001). Patients with labral degeneration also achieved the clinically significant thresholds of MCID, PASS, and SCB less frequently at 2-year follow-up than patients with mild or no labral degeneration (P = .016; P < .001; P = .001). The proportion of patients in the labral degeneration group who achieved maximal outcome improvement was lower than the proportion of patients in the no-degeneration group; however, this difference was not significant (P = .070). These analyses are summarized in Table 1.
      Table 1Demographics, Preoperative, and 2-Year Follow-Up International Hip Outcome Tool 12 Scores From Patients Undergoing Primary Hip Arthroscopy, Separated by the Presence or Absence of Labral Degeneration
      CharacteristicOverall, N = 613Control, N = 473
      Statistics presented: mean (standard deviation); number (% of sample).
      Degenerated Labrum, N = 140
      Statistics presented: mean (standard deviation); number (% of sample).
      P Value
      Statistical tests performed: Wilcoxon rank-sum test; χ2 test of independence.
      Age, y36 (13)33 (12)44 (11)<.001
      Body mass index24.5 (3.9)24.6 (3.9)24.2 (3.7).4
      Sex
       Female378 (62%)286 (60%)92 (66%)
       Male235 (38%)187(40%)48 (34%)
      Preoperative iHOT-1236 (18)37 (19)33 (17).037
      Time of follow-up, y2.01 (0.18)2.01 (0.13)2.03 (0.26)
      Two-year iHOT-1274 (24)76 (23)66 (27)<.001
      iHOT-12 MCID500 (82%)396 (84%)104 (74%).016
      iHOT-12 PASS443 (72%)359 (76%)84 (60%)<.001
      iHOT-12 SCB267 (44%)223 (47%)44 (37%).001
      iHOT-12 MOI415 (68%)326 (69%)77 (55%).070
      iHOT-12, International Hip Outcome Tool-12; MCID, minimal clinically important difference; MOI, maximal outcome improvement; PASS, patient-acceptable symptom scale; SCB, substantial clinical benefit.
      Statistics presented: mean (standard deviation); number (% of sample).
      Statistical tests performed: Wilcoxon rank-sum test; χ2 test of independence.
      The proportion of patients who exhibited acetabular cartilage damage at the time of arthroscopy and the severity of cartilage damage classified according to the Beck Scale (I, II, III, IV) was determined for each group. For the no degeneration cohort, 15% had grade I cartilage damage, 19% had grade II, 14% had grade III, and 8.3% had grade IV. For the degeneration cohort, 20% had grade I, 9.4% had grade II, 14% had grade III, and 7.8% had grade IV. A χ2 test of independence was performed to test for associations. There was no significant difference between the proportion of patients with acetabular cartilage damage between the 2 groups (P = .091, Table 2).
      Table 2Proportion of Each Cohort That Presented Acetabular Cartilage Damage According to the Beck Classification System, as Noted During Hip Arthroscopy
      CharacteristicOverall, N = 613Control, N = 473
      Statistics presented: number (% of sample).
      Degenerated Labrum, N = 140
      Statistics presented: number (% of sample).
      P Value
      Statistical tests performed: Wilcoxon rank-sum test; χ2 test of independence.
      Acetabular cartilage damage (Beck grade).091
       0230 (44%)168 (42%)62 (48%)
       187 (17%)61 (15%)26 (20%)
       289 (17%)77 (19%)12 (9.4%)
       375 (14%)57 (14%)18 (14%)
       443 (8.2%)33 (8.3%)10 (7.8%)
       Unknown897712
      Statistics presented: number (% of sample).
      Statistical tests performed: Wilcoxon rank-sum test; χ2 test of independence.
      After we controlled for patient age, BMI, sex, and preoperative iHOT-12 score using multivariate logistic regression models, we found labral degeneration to be an independent negative predictor for all clinically significant thresholds: MCID, PASS, and SCB. These predictions were noted using odds ratios with 95% confidence intervals. The results of these analyses are presented in Table 3.
      Table 3Multivariate Logistic Regression Model Controlling for Age, BMI, Sex, and Preoperative iHOT-12 Scores to Identify Significant Predictors of Achieving Clinical Thresholds at Two-Year Follow-Up
      MCIDPASSSCB
      ORCIP ValueORCIP ValueORCIP Value
      Preoperative iHOT-120.980.96-0.99<.0011.021.01-1.03<.0011.021.01-1.03<.001
      Age, y1.000.98-1.02>.91.000.98-1.02>.90.990.98-1.01.5
      Body mass index0.980.92-1.04.40.970.92-1.02.21.000.95-1.05>.9
      Sex
       Female
       Male0.720.46-1.12.140.890.60-1.32.61.110.78-1.58.6
      Labral Degeneration
       Control
       Degenerated labrum0.470.28-0.79.0040.500.32-0.77.0020.580.37-0.89.013
      BMI, body mass index; CI, confidence interval; iHOT-12, International Hip Outcome Tool-12; MCID, minimal clinically important difference; OR, odds ratio; PASS, patient-acceptable symptom scale; SCB, substantial clinical benefit.
      For the 613 surgeries included in the study, there were 7 complications: 1 patient in the nondegeneration group experienced neuropraxia postoperatively and 6 patients reported persistent pain after the operation, 5 in the nondegeneration group and 1 in the degeneration group. No statement of significance could be made regarding differences between the cohorts in regard to complications.

      Discussion

      Our analysis found that although both patients who presented with and without labral degeneration did improve post-hip arthroscopy, patients with labral degeneration reported iHOT-12 scores that were significantly lower than patients without significant labral degeneration. This finding supports our stated hypothesis. Patients with degeneration were also significantly less likely to meet the clinically significant thresholds of MCID, PASS, and SCB than patients without degeneration. It is important to note that patients with substantial labral degeneration still demonstrated significant improvement in patient-reported outcomes following labral repair, highlighting that labral repair is a viable treatment option for patients with labral tears who exhibit degeneration. Our study presents a multicenter, large-sample size investigation of the impacts of labral degeneration on mid-term postoperative outcomes following hip arthroscopy for labral repair.
      By analyzing the outcomes of 613 patients from 5 centers across the United States, our data improve upon analyses that have been limited by small sample sizes and a focus on specific patient populations. In addition, our analyses excluded patients with a Tönnis grade of 2 or greater. This inclusion criterium focused our analysis on labral degeneration apart from the impacts of osteoarthritis. In addition to avoiding the confounding influence of hip osteoarthritis, our investigation analyzed whether the presence of acetabular cartilage damage could confound our associations. No significant differences were found between the groups in terms of the proportion of patients with acetabular cartilage damage. These data further confirm that labral degeneration alone is responsible for poorer outcomes following hip arthroscopy.
      Our investigation classified labral degeneration as calcification, ossification, and/or yellowish discoloration at least 50% of the labral substance at any segment of the labrum upon visual inspection and/or probing. Previous investigations have characterized labral degeneration according to these characteristics
      • Beck E.C.
      • Kunze K.N.
      • Friel N.A.
      • et al.
      Is there a correlation between outcomes after hip arthroscopy for femoroacetabular impingement syndrome and patient cortical bone thickness?.
      ; however, as of now, no classification method has been developed for labral degeneration. Therefore, our classification scheme is a novel method for classifying labral degeneration. An analysis of the interrater reliability of this classification scheme was performed at the initiative of the registry and recorded moderate reliability (Cohen’s kappa coefficient of 0.51) with 79% average agreement between investigators.
      • Emmons B.R.
      • Christoforetti J.J.
      • Matsuda D.K.
      • et al.
      Arthroscopic classification of intra-articular hip pathology demonstrates at best moderate interrater reliability.
      Degeneration of the hip acetabular labrum is associated with greater hip pain in patients with labral tears.
      • Trisolino G.
      • Favero M.
      • Dallari D.
      • et al.
      Labral calcification plays a key role in hip pain and symptoms in femoroacetabular impingement.
      In a study of 80 patients with labral degeneration, defined in this study as labral calcification, degeneration was associated with greater hip pain and poorer functional scores preoperatively, measured via the Hip Disability and Osteoarthritis Outcome Score, than patients without degeneration.
      • Trisolino G.
      • Favero M.
      • Dallari D.
      • et al.
      Labral calcification plays a key role in hip pain and symptoms in femoroacetabular impingement.
      Our data demonstrated that patients with both labral tears and degeneration reported lower preoperative iHOT-12 scores than patients with labral tears without degeneration, supporting these previous findings that labral degeneration is associated with greater pain preoperatively.
      Data support the assertion that labral degeneration is associated with age, as elderly populations exhibit a greater prevalence of degeneration than younger populations. A study of 1,151 hips found that older patients were likely to have unsalvageable labral tears characterized by tissue degeneration.
      • Nakashima H.
      • Tsukamoto M.
      • Ohnishi Y.
      • et al.
      Clinical and radiographic predictors for unsalvageable labral tear at the time of initial hip arthroscopic management for femoroacetabular impingement.
      The association of degenerate labrums with increasing age may exist also in the absence of pain.
      • Domzalski M.E.
      • Synder M.
      • Karauda A.
      • Papierz W.
      Histological changes of the acetabular labrum in coxarthrosis: Labral degeneration and repair.
      Our data provide further evidence that labral degeneration is more prevalent among older patient populations. Because patients with labral degeneration tend to be older and report greater pain preoperatively, age and preoperative functional scores could act as confounding factors in an analysis of the impacts of labral degeneration. Our analysis controlled for these patient characteristics by using logistic regression models to control for patient age, BMI, sex and preoperative iHOT-12 scores. This analysis confirmed that labral degeneration impacts outcomes independently of these patient characteristics.
      While significant associations have been noted between labral degeneration and age, the link between labral degeneration and other age-related pathologies, such as osteoarthritis, is less clear. Because the labrum acts as a soft-tissue cushion that protects articular cartilage, degeneration of the labrum has been hypothesized to result in further degenerative joint pathologies.
      • Kapetanakis S.
      • Dermon A.
      • Gkantsinikoudis N.
      • Kommata V.
      • Soukakos P.
      • Dermon C.R.
      Acetabular labrum of hip joint in osteoarthritis: A qualitative original study and short review of the literature.
      An investigation into age-related degenerative pathologies demonstrated an association between labral degeneration, the early development of osteoarthritis, and hip pain.
      • Hubert J.
      • Hawellek T.
      • Moe M.
      • et al.
      Labral calcification in end-stage osteoarthritis of the hip correlates with pain and clinical function.
      However, another study reported no association between labral degeneration and the presence or severity of osteoarthritis,
      • Domzalski M.E.
      • Synder M.
      • Karauda A.
      • Papierz W.
      Histological changes of the acetabular labrum in coxarthrosis: Labral degeneration and repair.
      demonstrating that labral degeneration may be present in the absence of osteoarthritis. By excluding patients with a Tönnis osteoarthritis grading of 2 or greater, our study formed a cohort of patients with labral degeneration apart from osteoarthritis, providing evidence that degeneration of the labrum does not necessarily coincide with other degenerative changes of the hip.
      Most current studies do not isolate degeneration as a variable of analysis. Investigations that do analyze the surgical outcomes of patients with labral degeneration have focused on degeneration in the setting of osteoarthritis. A study of 21 patients undergoing hip arthroscopy for femoroacetabular impingement found that labral calcification was associated with lower postoperative Hip Disability and Osteoarthritis Outcomes Scores regardless of patient age. In this cohort, which included patients with osteoarthritis, 67% of patients who presented with labral calcification were noted to have synovial inflammation and articular cartilage damage. Although 74% of the patients with articular cartilage damage displayed isolated lesions on the acetabulum, 26% of the patients displayed diffuse cartilage damage on the acetabulum and femoral head.
      • Trisolino G.
      • Favero M.
      • Dallari D.
      • et al.
      Labral calcification plays a key role in hip pain and symptoms in femoroacetabular impingement.
      This cartilage damage would have been a likely cause of pain and could have confounded the results of the study. Because patients with osteoarthritis generally do not have favorable outcomes following arthroscopic treatment of labral tears,
      • Sogbein O.A.
      • Shah A.
      • Kay J.
      • et al.
      Predictors of outcomes after hip arthroscopic surgery for femoroacetabular impingement: A systematic review.
      ,
      • Viswanath A.
      • Khanduja V.
      Can hip arthroscopy in the presence of arthritis delay the need for hip arthroplasty?.
      the presence of osteoarthritis could be a confounding factor in the outcomes of patients with labral degeneration undergoing hip arthroscopy. Our data show that labral degeneration alone is a negative predictor of achieving clinically significant thresholds, by excluding patients with a Tönnis osteoarthritis score of 2 or greater.
      Acetabular cartilage damage also has been demonstrated to impact the outcomes of hip arthroscopy.
      • Byrd J.W.T.
      • Jones K.S.
      Arthroscopic acetabular labral repair in patients over the age of 60 years: A matched case-control study.
      ,
      • McClincy M.P.
      • Lebrun D.G.
      • Tepolt F.A.
      • Kim Y.J.
      • Yen Y.M.
      • Kocher M.S.
      Clinical and radiographic predictors of acetabular cartilage lesions in adolescents undergoing hip arthroscopy.
      A study of 20 patients older than the age of 60 who underwent arthroscopic labral repair found that all patients who converted to total hip arthroplasty within 2 years had grade III or grade IV acetabular cartilage damage.
      • Byrd J.W.T.
      • Jones K.S.
      Arthroscopic acetabular labral repair in patients over the age of 60 years: A matched case-control study.
      Our finding no significant differences between our cohorts in terms of the severity of acetabular cartilage damage ensured that chondrosis did not act as a confounding factor. Thus, labral degeneration appears to impact surgical outcomes independently of acetabular cartilage damage.
      Reports focusing on the surgical outcomes of patients with labral degeneration have focused on the technique of labral reconstruction using an allograft, which neglects to consider patients with labral degeneration who undergo labral repair. The decision to pursue labral reconstruction over labral repair may occur intraoperatively; however, preoperative decision-making is often necessary for the procurement of the graft needed for reconstruction. Degenerate labral tissue has been cited as an indication for labral reconstruction over other surgical interventions
      • Harris J.D.
      Hip labral repair: options and outcomes.
      ; however, magnetic resonance imaging (MRI) is generally used as the diagnostic tool to assess labral degeneration and the sensitivity of uncovering this pathology is imperfect.
      • Morgan P.
      • Crawford A.
      • Marette S.
      • et al.
      Using a simplified version of a common surgical grading scale for acetabular labral tears improves the utility of preoperative hip MRI for femoroacetabular impingement.
      Therefore, it is likely that many patients with labral degeneration are treated via a labral repair because of the lack of preparation for a reconstruction. Thus, our data on degeneration in the context of labral repair are useful.
      The outcomes of patients with labral degeneration who underwent labral reconstruction have been generally positive. A study of 34 patients undergoing labral reconstruction for a variety of pathologies, including labral degeneration, reported significant improvements in the modified Harris Hip Score (mHHS), iHOT-12, Hip Outcome Score, and SF-12 physical score.
      • Carreira D.S.
      • Kruchten M.C.
      • Emmons B.R.
      • Martin R.L.
      Arthroscopic labral reconstruction using fascia lata allograft: Shuttle technique and minimum two-year results.
      Another study of 131 hips reported significant improvement in mHHS, Lower Extremity Functional Scale, and visual analog pain scale after labral reconstruction; however, the study reported a failure rate of 13.7%, with 18 patients requiring revision surgery.
      • 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.
      The outcomes of our patients with labral degeneration who underwent labral repair mirror those of patients with degeneration who underwent labral reconstruction in that functional scores did improve after both interventions.
      Given our findings that labral degeneration negatively impacts the outcomes of patients following hip arthroscopy who underwent labral repair, further investigation is necessary related to the role of repair versus reconstruction. For patients with challenging labral pathologies, including degeneration, a study by Scanaliato et al.
      • 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.
      found no significant differences in patient-reported outcomes between the group who underwent repair (N = 99) and the group who underwent reconstruction (N = 63). Controlling for the factor of degeneration in outcome studies is limited. A multicenter study of 416 patients also found no significant differences between patients who underwent labral repair or labral reconstruction using iHOT-12, the mHHS and the Hip Outcome Score.
      • Bodendorfer B.M.
      • Alter T.D.
      • Carreira D.S.
      • et al.
      Multicenter outcomes after primary hip arthroscopy: A comparative analysis of two-year outcomes after labral repair, segmental labral reconstruction, or circumferential labral reconstruction.
      A review comparing the outcomes of patients who underwent labral repair versus labral reconstruction does improve patient functional scores postoperatively; however, the outcomes are not any greater than those of patients who underwent labral repair.
      • Safran N.
      • Rath E.
      • Haviv B.
      • Atzmon R.
      • Amar E.
      The efficacy of labral reconstruction: A systematic review.
      Other investigations did find differences between the outcomes of repair and reconstruction. In a study of 312 hips, failure, defined as need for revision hip surgery, was 3.29 times more likely in patients aged 40 and older who underwent labral repair versus reconstruction. This difference was not found in patients younger than 40 years.
      • White B.J.
      • Patterson J.
      • Scoles A.M.
      • Lilo A.T.
      • Herzog M.M.
      Hip arthroscopy in patients aged 40 years and older: Greater success with labral reconstruction compared with labral repair.
      Another investigation of 29 patients found that labral repairs had a 31% failure rate, defined as need for revision surgery within 5 years, whereas no hips that underwent labral reconstruction failed.
      • White B.J.
      • Patterson J.
      • Herzog M.M.
      Bilateral hip arthroscopy: Direct comparison of primary acetabular labral repair and primary acetabular labral reconstruction.
      The decision to pursue reconstruction instead of repair is generally planned preoperatively by factoring the patient’s physical examination, age, and the severity of labral degeneration as noted on MRI.
      • Perets I.
      • Rybalko D.
      • Mu B.H.
      • et al.
      In revision hip arthroscopy, labral reconstruction can address a deficient labrum, but labral repair retains its role for the reparable labrum: A matched control study.
      Given the results of our study and previous investigations it may be worthwhile to plan for a possible labral reconstruction for older patients, patients with greater preoperative pain, and patients with degeneration as noted on MRI; however, the evidence is not definitive.
      Despite significant differences between the outcomes of the degeneration and control cohorts, our data show significant improvement in patient-reported outcomes for patients with degeneration following labral repair, with healthy labral tissue correlated with superior outcomes. Evidence for whether labral repair or reconstruction is a more effective intervention for patients with labral tears exhibiting degeneration remains unclear. Further research is warranted to investigate the optimal surgical interventions for this patient population.

      Limitations

      Because a registry was used for data collection, reporting and selection biases are limitations of this study. Given the multicenter nature of this study, differences in inter- and intrarater reliability are possible when grading the extent of labral degeneration. In addition, the patient population in this study is composed of patients whose labral degeneration was noted intraoperatively during labral repair, excluding patients with more advanced labral degeneration noted preoperatively who were not candidates for labral repair. Because acetabular cartilage damage was not included in our multivariate analysis, it is still possible that the presence of cartilage damage could have been a confounding factor in our results, given the number of unknowns.

      Conclusions

      The results of our study conclude that patients with nondegenerative labral tissue at the time of repair have superior patient-reported outcomes at mid-term follow-up. The presence of labral degeneration was a negative predictor of achieving clinically significant thresholds after controlling for patient age, BMI, sex, and baseline iHOT-12 scores.

      Supplementary Data

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