Labral Reconstruction

Hip arthroscopy is minimally invasive surgical technique pioneered in the 1990s.  In the 1990s, the concept of femoroacetabular impingement (FAI) was also introduced by Reinhold Ganz in Switzerland.  Hip arthroscopy has advanced rapidly over the past few decades and is widely utilized throughout the United States and the world to address FAI by removing excess bone (pincer lesion) at the rim of the hip socket (acetabulum) using a bur in a procedure called acetabuloplasty.  Excess bone at the femoral neck (cam lesion) is also removed using a bur in a procedure called a femoroplasty. 

The acetabular labrum is a cartilage gasket at the rim of the acetabulum and is often damaged or torn in setting of underlying hip instability or femoroacetabular impingement.  In the early days of hip arthroscopy (1990s and 2000s), labral tears were often treated with labral debridement, which is essentially removal of the damaged tissue with a shaver.

Labral Repair vs. Debridement

Because the labrum helps establish a suction seal, which plays a key role in stabilizing the hip joint and preserving its function, labral repair was advocated over debridement in the 2010s.

Several studies have demonstrated the benefits of hip labral repair compared to labral debridement, particularly in terms of preserving hip function and reducing the risk of further surgical interventions. One study published in 2022 and performed at Massachusetts General Hospital (MGH) is highlighted below.

This MGH study compared labral repair and debridement and found that patients undergoing repair had a significantly lower risk of conversion to total hip replacement (THA) within ten years. Specifically, 22% of patients in the debridement group required THA compared to only 5% in the repair group. Repair was also associated with improved joint stability and better long-term hip preservation.

Kucharik et al. Arthroscopic Acetabular Labral Repair Versus Labral Debridement: Long-term Survivorship and Functional Outcomes. The Orthopaedic Journal of Sports Medicine. Nov 2022.

https://advances.massgeneral.org/ortho/journal.aspx?id=2342

Unfortunately, there are cases when a patient’s native labral tissue is too degenerative, damaged or deficient to be repaired.  Therefore, the labrum would need to be debrided or excised, resulting in a theoretically-worse outcome than repair, which is particularly worrisome if the patient is young and active.  

If the patient is physiologically young and active, and does not have significant osteoarthritis, then restoration of the labral tissue may re-establish the suction seal.  In turn, this would improve joint stability and help maintain a healthy layer of joint fluid, which ultimately decreases the stress on the cartilage and may delay the need for a hip replacement.

Description of Labral Reconstruction

Labral reconstruction involves the creation of a new acetabular labrum when the patient’s native labrum is badly damaged and cannot be repaired.  Dr. Pappas uses fascia lata allograft (Allosource, Stryker), which is a sheet of fibrous tissue derived from the thigh of a cadaver. This collagen tissue is extensively cleaned and processed by the Allosource. In the OR, it fashioned into a durable, cylindrical graft for insertion into the patient’s hip (Figure 1).

Decision Making: Labral Debridement vs. Repair vs. Reconstruction

If a labrum is not repairable, it stands to reason that reconstructing the labrum would better restore the function and longevity of the hip joint than a labral debridement.

Labral reconstruction is associated with improved joint stability, pain relief, and functional outcomes when compared to debridement or poorly executed repairs. Reconstruction can restore the suction seal and biomechanical properties of the joint, crucial for long-term joint preservation.

A review article published in 2017 in the Journal of the American Association of Orthopaedic Surgeons (JAAOS) summarized the decision-making regarding debridement vs. repair vs. reconstruction of the acetabular labrum.  Based on available scientific evidence, this review article concluded the following:

“In young adults with a nonviable or calcified labrum, the labrum should be reconstructed if technically feasible. A partially calcified labrum may be repaired if enough labral tissue is present after excision of the existing calcification, however.  If the labrum is unstable but viable, a repair should be performed unless the labrum has poor vascularity. In such cases, a selective labral débridement may be performed. In cases of instability caused by ligamentous laxity and/or dysplasia, it is particularly important to preserve or reconstruct the labrum because of its importance as a static stabilizer.”

Decision Making for Labral Treatment in the Hip:  Repair Versus Debridement Versus Reconstruction.  Journal of the American Association of Orthopaedic Surgeons (JAAOS) Vol 25, No 3, March 2017.

Labral Reconstruction Demonstrates Superior Outcomes at 5-Year Follow Up

Studies with a minimum 5-year follow-up indicate that labral reconstruction provides superior survivorship and patient-reported outcomes compared to repair, especially when the native labrum is insufficient for a successful repair. This suggests that reconstruction has significant long-term benefits and may delay the progression of osteoarthritis in some patients.

Direct comparisons also show that patients undergoing reconstruction report higher satisfaction scores and better functionality compared to those with primary repair or debridement, particularly in cases of segmental defects or non-viable tissue.

Minimum 5-Year Outcomes of Arthroscopic Hip Labral Reconstruction With Nested Matched-Pair Benchmarking Against a Labral Repair Control Group. The American Journal of Sports Medicine 2019;47(9):2045–2055

Labral reconstruction is usually reserved for cases with irreparable labral damage or revision surgeries.

Irreparable Labral Damage

In the first scenario (Figure 2), the patient is undergoing primary hip arthroscopy, and the labrum is found to be extensively torn and degenerative and is deemed irreparable by the surgeon.  If the patient is older (more than 50 years of age), has medical comorbidities, and/or has significant osteoarthritis or cartilage wear, a labral debridement may be performed (i.e., the torn labrum is removed using a shaver).

However, if the patient is younger (typically less than 50 years of age), is relatively healthy, and has little-to-no osteoarthritis or cartilage wear, a labral reconstruction is often performed.  As a result, the patient only undergoes one surgery that typically involves all 3 procedures: femoroplasty, acetabuloplasty, and labral reconstruction.

Revision Surgeries

In the second scenario (Figure 3), a patient has undergone previous hip arthroscopy for a labral repair but continues to remain painful postoperatively despite at least 4 months of post-operative management including physical therapy.  Typically, this is the result of repairing a labrum that is degenerative and does not heal adequately despite repair.  As a result, if the patient is young and active, and does not have significant osteoarthritis or cartilage damage, then they are brought back to the operating room for a revision hip arthroscopy to perform the labral reconstruction.  In addition, they may require a revision acetabuloplasty or revision femoroplasty if there has been any unexpected bone regrowth since their first procedure. 

A 16-year-old patient undergoes hip arthroscopy for labral repair (A-D).  Due to continued pain, she undergoes a revision hip arthroscopy 17 months later for labral reconstruction (E-H).  Her labral repair was compromised (E) by bone regrowth at the acetabular rim (F).  A revision acetabuloplasty was performed (G) and the labrum was reconstructed with cadaver graft.

Summary

Research comparing hip labral reconstruction with labral debridement and repair supports the role of reconstruction, particularly in cases where the labrum is irreparable or severely damaged.

Labral reconstruction a more complex and challenging surgery than labral repair.

Surveys indicate only 10-20% of hip arthroscopy surgeons perform labral reconstruction regularly. Labral reconstruction is more commonly performed by high-volume of hip arthroscopy surgeons, who perform more than 50 hip arthroscopy surgeries per year. Reports suggest that approximately 30–50% of high-volume hip surgeons include labral reconstruction in their practice. Furthermore, a survey published in 2019, revealed only 25% of high-volume hip arthroscopy surgeons performed over 20 labral reconstructions per year (Journal of Hip Preservation Surgery. Vol. 6, No. 1, pp. 41-49)

Dr. Pappas is high-volume hip arthroscopy surgeon who is experienced with labral reconstruction surgery. He meticulously performs more than 40-50 labral reconstruction surgeries per year.