Editorial Commentary: Hip Primary Labral Repair Versus Reconstruction: Equally Successful Outcomes Can Be Achieved Based on Proper Indications

Abstract

One of the core principles of hip arthroscopy is preservation of the acetabular labrum. Compromise of the biomechanical function of the labrum underlies a significant symptom source in patients undergoing hip preservation surgery. As surgical techniques continue to improve and evolve beyond labral repair, increased use of advanced arthroscopic procedures like segmental and circumferential reconstruction shed further light on the optimal labral intervention. In the revision setting, labral deficiency warrants labral reconstruction or augmentation. Both segmental and circumferential techniques may significantly improve patient-reported outcomes. However, in the primary setting, controversy exists not necessarily in the surgical technique, but more in the indications to perform which specific labral intervention. Reasonable indications for primary labral reconstruction include a calcified or ossified labrum, irreparable labral tissue, and hypotrophy of the labrum (less than 2-3 mm) with a proven deficient suction seal without resistance to axial distraction. Short-term multicenter studies demonstrate similar success rates between primary labral reconstruction and repair using validated patient-report outcome scores. Mid-and long-term clinical and economic investigations comparing labral reconstruction and repair are needed to determine the role of primary reconstruction in modern arthroscopic hip preservation surgery.

Editorial Commentary: Surgeons Planning Hip Labral Arthroscopic Repair Should Have a Backup Plan of Labral Reconstruction or Augmentation Based on Intraoperative Labral Degeneration, Hypoplasia, or Ossification

“…Since 50% labral degeneration predicts that 26e63% of these patients will never reach clinical improvement, do we need an intraoperative backup plan? [10][11][12] This study challenges whether 50% labral degeneration discovered intraoperatively should be considered a relative contraindication for primary repair. Future ones should investigate whether repaired degenerative labra are capable of reconstituting the appropriate mechanical functions of the labrum by assessing outcomes of preservation such as advancement of osteoarthritis and conversion to arthroplasty.…”

“…Their group then reviewed, retrospectively, 103 patients who had undergone primary arthroscopic labral repair, finding that those identified with hypoplastic labra on preoperative MRIs demonstrated significantly poorer outcome measures at 2 years postoperatively, which contrasts with the aforementioned findings of Kaplan et al 9 These studies, among others, have stimulated discussion on whether preoperative assessment of labral width can influence whether patients will require augments or labral reconstruction in lieu of primary repair. [10][11][12] However, we must not confuse the hypoplastic labrum that may potentially have normal tissue quality with a degenerative one. Patients in this study classified as having labrum degenerated more than 50% were defined on the basis of calcification, ossification, and/or yellowish discoloration of at least 50% of the labral substance.…”

“…1 Considering the unique qualities of the labral substance that contribute to hip stability, the suction seal effect, and the maintenance of appropriate fluid mechanics within the hip joint, it is reasonable to question whether these mechanical properties may be jeopardized more in a degenerative labrum than in a hypoplastic one. 4,10,13 Hence, are we even measuring the most important outcomes when evaluating iHOT-12 and other scores on other patient-reported outcome measures at 1 and 2 years postoperatively?…”

“…In this study, patients in the labral degeneration group were significantly older (44 vs. 33 years old, p < .001), and while multivariate regression analysis did not identify age as a negative predictor of outcomes, it seems that we should be measuring whether these older patients with advanced labral degeneration actually have functionally salvageable labrums 1 (i.e., ones that would reconstitute the appropriate suction seal, joint stability, and fluid mechanics integral to joint preservation of the hip). 4,10,13 Therefore, it would be interesting at 5-year follow up to learn the rates of revision surgery, the advancement of osteoarthritis, or conversion to arthroplasty in these patients, when their mean age approaches 50 and they are more likely to be indicated for hip arthroplasty than revision arthroscopy. Since 50% labral degeneration predicts that 26e63% of these patients will never reach clinical improvement, do we need an intraoperative backup plan?…”