At Issue

At Issue: Hip labral reconstruction

Is the optimal method of hip labral reconstruction segmental or circumferential?

Circumferential labral reconstruction becomes more reproducible with training, experience

The indications for acetabular labral reconstruction are controversial. The literature is full of reports that show good results with labral treatment ranging from minimal debridement to repair or segmental reconstruction and ultimately to circumferential reconstruction. Also reflected in the literature is the shared experience of surgeons who have dedicated their careers to helping people with non-arthritic hip problems. In other words, some times it may not matter how we treat the labrum; other times it matters quite a bit. Widely cited work that shows superior results with repair vs. debridement suggests that patients who underwent debridement, but did not fare well had undertreated labral pathology. However, we must be aware that the majority of these patients still did well. We can infer from such results, as well as from many other published reports and our shared experience, that how we treat the labrum does matter to a consequential percentage of our patients.

There is a paucity of literature comparing segmental to circumferential reconstruction. However, based on my experience with both of these techniques, circumferential is the better option.

Andrew B. Wolff

Avoid under-treatment

To drill down on this topic, it helps to consider the role of the labrum as a stabilizing structure in the hip, which is supported by scientific evidence. There is also good evidence that the labrum can be a pain generator, suggesting that if we can retain or restore the stabilizing features of the labrum and eliminate the pain generators, we can give patients the best opportunity to get over their hip problem. Some labra simply cannot be repaired, including labra that are ossified, damaged beyond repair, have failed previous repair or debridement, or sit atop of a severe coxa profunda deformity. As debridement only helps eliminate potential pain-generating tissue, this procedure is done with the hopes that the patient being treated is someone who does not need a functional labrum to optimize his or her hip function and that we, as the surgeon, have identified the correct portion of the labrum to debride. Debridement in this scenario, therefore, risks under-treatment.

A segmental labral reconstruction also risks under-treatment. Although there are clearly hips where the area of labral pathology is well-defined, in many hips that area is not as well defined. Segmental reconstruction, like debridement, presumes the surgeon knows the exact area of pathology and can treat it reproducibly. A circumferential reconstruction eliminates the variable of undertreating an area of labral and acetabular pathology.

I would argue it is technically more difficult to restore a suction seal with a segmental reconstruction than with a circumferential reconstruction. With a segmental reconstruction, there are two sites of interface between the native labral tissue and the graft. The graft-labral junction is inherently weak and is often puckered or everted off the femoral head when the hip is out of traction, substantially limiting the efficacy of the suction seal.

Graft-labral junctions of concern

Durability of graft-labral interfaces is of concern. Because both of these junctions are in the region of pathology as determined by the surgeon, they are placed in the areas of highest stress that have already failed, which is why the patient needed surgery in the first place. Circumferential reconstruction eliminates any graft-labral interface issues because the graft is fixed at the far antero-inferior and far postero-inferior acetabulum. With a properly trained surgeon who has practiced the procedure, circumferential reconstruction will reproducibly restore the suction seal in the patient’s hip without the risk of subsequent breakdown at the graft-labral interface.

Circumferential reconstruction with fascia lata restores the suction seal.

Source: Andrew B. Wolff, MD

In summary, labral reconstructions are performed to reduce the risk of failure due to under-treatment of labral pathology. With segmental reconstruction, this risk is still present as the surgeon relies upon his or her perception of where the pathology lies. Additionally, placement of two graft-labral interfaces in high stress areas that have already failed introduces a level of risk that does not exist with circumferential reconstruction. Circumferential reconstruction offers an extremely reproducible mechanical restoration of the suction seal and hip stability without the risk of subsequent graft-labral interface breakdown.

Keep in mind that the type of treatment done on the labrum only matters in a subset of patients. If the suction seal is not restored at the end of the operation in a durable manner, you have essentially performed a riskier and more expensive debridement. Circumferential labral reconstruction is a difficult operation to master that eventually becomes very reproducible, but only after the surgeon has extensive training and experience.

Disclosure: Wolff reports he is a consultant for Stryker and AlloSource.

Reconstruction technique should correspond to type, extent of labral damage

There have been rapid advancements in hip arthroscopy to treat labral tears. Since a study by Christopher M. Larson, MD, and his colleagues showed improved outcomes with labral repair compared with labral debridement, labral repair has become accepted as superior to debridement. The type of treatment is less clear if the labrum is irreparably torn. Studies have shown that labral reconstruction can yield results that are similar to those of primary labral repair, and that labral reconstruction is part of the armamentarium of most high-volume hip arthroscopy surgeons. The controversy now concerns how much of the labrum should be reconstructed. While initial studies focused on segmental labral reconstruction or replacing the labrum that is too damaged to repair, some surgeons advocate for performing global labral reconstruction. Although published results show good results with both techniques, they are technically and philosophically different. There are some instances in which I perform a 270° (global) reconstruction. But, for the most part, I prefer segmental reconstruction of only the damaged/torn labrum for the reasons outlined here.

Derek Ochiai

Damaged labrum

First, if only part of the labrum is torn and damaged, why remove it? Most labral tears are caused by femoro-acetabular impingement (FAI), which causes mechanical degeneration of the labrum. At the time of surgery, any damage to the labrum is evident. However, often the posterior labrum is spared and, in fact, it may look pristine. Obviously, this area of the labrum was resistant to the insidious nature of the impingement. If it is not subject to an intervention, FAI can cause further damage to any remaining intact labrum. During labral reconstruction, FAI can be addressed, a step that should further protect the normal labrum from damage. When performing a hip labral repair, surgeons do not put sutures around the normal, untorn labrum. Similarly, with labral reconstruction, what is intact should be left intact.

The hip labrum is shown after segmental reconstruction.

Source: Derek Ochiai, MD

Bone sparing procedure

Second, segmental reconstruction is more bone sparing. Labral reconstruction requires use of multiple anchors, all of which take up real estate in the acetabulum. A typical segmental labral reconstruction that I perform can use four to six anchors. However, a global reconstruction may require ten or more anchors. Although results of labral reconstruction are good thus far, most studies do not show a 100% success rate, and having a more intact acetabular rim may make revision surgery more feasible. In fact, I deliberately slightly undersize the graft when initially fixing the anterior and posterior parts of the graft, causing the graft to slightly bowstring across the face of the socket. The middle anchors then pull the graft up to the rim and the increased graft tension adds stability to the construct. This sometimes allows me to use a few less anchors.

Finally, I believe it is hubris to believe that labral reconstruction functions exactly the same as the intact labrum. Marc J. Philippon, MD, and his recently published results of labral augmentation for hypoplastic labra, which showed superior results compared to segmental reconstruction. Replacing a suction seal of type II cartilage of the labrum with Type I collagen of a tendon may not be the same. If part of the labrum is intact and functional, preserving this part makes sense.

Both segmental and global hip labral reconstruction can benefit from their use in selected patients. A large, multicenter trial would be needed to parse out the differences in benefits of these procedures. While we await that endeavor, we should keep in mind the fact that hip arthroscopy is a phenomenal diagnostic tool, and base our treatment on that. If there is global labral damage at time of reconstruction, by all means do a global hip labral reconstruction. If there is segmental damage only, consider a segmental reconstruction.

Disclosure: Ochiai reports he is a paid consultant for Breg and for Conmed Linvatec; he received IP royalties from Smith & Nephew and has stock or stock options with Tenex Health.

Circumferential labral reconstruction becomes more reproducible with training, experience

The indications for acetabular labral reconstruction are controversial. The literature is full of reports that show good results with labral treatment ranging from minimal debridement to repair or segmental reconstruction and ultimately to circumferential reconstruction. Also reflected in the literature is the shared experience of surgeons who have dedicated their careers to helping people with non-arthritic hip problems. In other words, some times it may not matter how we treat the labrum; other times it matters quite a bit. Widely cited work that shows superior results with repair vs. debridement suggests that patients who underwent debridement, but did not fare well had undertreated labral pathology. However, we must be aware that the majority of these patients still did well. We can infer from such results, as well as from many other published reports and our shared experience, that how we treat the labrum does matter to a consequential percentage of our patients.

There is a paucity of literature comparing segmental to circumferential reconstruction. However, based on my experience with both of these techniques, circumferential is the better option.

Andrew B. Wolff

Avoid under-treatment

To drill down on this topic, it helps to consider the role of the labrum as a stabilizing structure in the hip, which is supported by scientific evidence. There is also good evidence that the labrum can be a pain generator, suggesting that if we can retain or restore the stabilizing features of the labrum and eliminate the pain generators, we can give patients the best opportunity to get over their hip problem. Some labra simply cannot be repaired, including labra that are ossified, damaged beyond repair, have failed previous repair or debridement, or sit atop of a severe coxa profunda deformity. As debridement only helps eliminate potential pain-generating tissue, this procedure is done with the hopes that the patient being treated is someone who does not need a functional labrum to optimize his or her hip function and that we, as the surgeon, have identified the correct portion of the labrum to debride. Debridement in this scenario, therefore, risks under-treatment.

A segmental labral reconstruction also risks under-treatment. Although there are clearly hips where the area of labral pathology is well-defined, in many hips that area is not as well defined. Segmental reconstruction, like debridement, presumes the surgeon knows the exact area of pathology and can treat it reproducibly. A circumferential reconstruction eliminates the variable of undertreating an area of labral and acetabular pathology.

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I would argue it is technically more difficult to restore a suction seal with a segmental reconstruction than with a circumferential reconstruction. With a segmental reconstruction, there are two sites of interface between the native labral tissue and the graft. The graft-labral junction is inherently weak and is often puckered or everted off the femoral head when the hip is out of traction, substantially limiting the efficacy of the suction seal.

Graft-labral junctions of concern

Durability of graft-labral interfaces is of concern. Because both of these junctions are in the region of pathology as determined by the surgeon, they are placed in the areas of highest stress that have already failed, which is why the patient needed surgery in the first place. Circumferential reconstruction eliminates any graft-labral interface issues because the graft is fixed at the far antero-inferior and far postero-inferior acetabulum. With a properly trained surgeon who has practiced the procedure, circumferential reconstruction will reproducibly restore the suction seal in the patient’s hip without the risk of subsequent breakdown at the graft-labral interface.

Circumferential reconstruction with fascia lata restores the suction seal.

Source: Andrew B. Wolff, MD

In summary, labral reconstructions are performed to reduce the risk of failure due to under-treatment of labral pathology. With segmental reconstruction, this risk is still present as the surgeon relies upon his or her perception of where the pathology lies. Additionally, placement of two graft-labral interfaces in high stress areas that have already failed introduces a level of risk that does not exist with circumferential reconstruction. Circumferential reconstruction offers an extremely reproducible mechanical restoration of the suction seal and hip stability without the risk of subsequent graft-labral interface breakdown.

Keep in mind that the type of treatment done on the labrum only matters in a subset of patients. If the suction seal is not restored at the end of the operation in a durable manner, you have essentially performed a riskier and more expensive debridement. Circumferential labral reconstruction is a difficult operation to master that eventually becomes very reproducible, but only after the surgeon has extensive training and experience.

Disclosure: Wolff reports he is a consultant for Stryker and AlloSource.

PAGE BREAK

Reconstruction technique should correspond to type, extent of labral damage

There have been rapid advancements in hip arthroscopy to treat labral tears. Since a study by Christopher M. Larson, MD, and his colleagues showed improved outcomes with labral repair compared with labral debridement, labral repair has become accepted as superior to debridement. The type of treatment is less clear if the labrum is irreparably torn. Studies have shown that labral reconstruction can yield results that are similar to those of primary labral repair, and that labral reconstruction is part of the armamentarium of most high-volume hip arthroscopy surgeons. The controversy now concerns how much of the labrum should be reconstructed. While initial studies focused on segmental labral reconstruction or replacing the labrum that is too damaged to repair, some surgeons advocate for performing global labral reconstruction. Although published results show good results with both techniques, they are technically and philosophically different. There are some instances in which I perform a 270° (global) reconstruction. But, for the most part, I prefer segmental reconstruction of only the damaged/torn labrum for the reasons outlined here.

Derek Ochiai

Damaged labrum

First, if only part of the labrum is torn and damaged, why remove it? Most labral tears are caused by femoro-acetabular impingement (FAI), which causes mechanical degeneration of the labrum. At the time of surgery, any damage to the labrum is evident. However, often the posterior labrum is spared and, in fact, it may look pristine. Obviously, this area of the labrum was resistant to the insidious nature of the impingement. If it is not subject to an intervention, FAI can cause further damage to any remaining intact labrum. During labral reconstruction, FAI can be addressed, a step that should further protect the normal labrum from damage. When performing a hip labral repair, surgeons do not put sutures around the normal, untorn labrum. Similarly, with labral reconstruction, what is intact should be left intact.

The hip labrum is shown after segmental reconstruction.

Source: Derek Ochiai, MD

Bone sparing procedure

Second, segmental reconstruction is more bone sparing. Labral reconstruction requires use of multiple anchors, all of which take up real estate in the acetabulum. A typical segmental labral reconstruction that I perform can use four to six anchors. However, a global reconstruction may require ten or more anchors. Although results of labral reconstruction are good thus far, most studies do not show a 100% success rate, and having a more intact acetabular rim may make revision surgery more feasible. In fact, I deliberately slightly undersize the graft when initially fixing the anterior and posterior parts of the graft, causing the graft to slightly bowstring across the face of the socket. The middle anchors then pull the graft up to the rim and the increased graft tension adds stability to the construct. This sometimes allows me to use a few less anchors.

PAGE BREAK

Finally, I believe it is hubris to believe that labral reconstruction functions exactly the same as the intact labrum. Marc J. Philippon, MD, and his recently published results of labral augmentation for hypoplastic labra, which showed superior results compared to segmental reconstruction. Replacing a suction seal of type II cartilage of the labrum with Type I collagen of a tendon may not be the same. If part of the labrum is intact and functional, preserving this part makes sense.

Both segmental and global hip labral reconstruction can benefit from their use in selected patients. A large, multicenter trial would be needed to parse out the differences in benefits of these procedures. While we await that endeavor, we should keep in mind the fact that hip arthroscopy is a phenomenal diagnostic tool, and base our treatment on that. If there is global labral damage at time of reconstruction, by all means do a global hip labral reconstruction. If there is segmental damage only, consider a segmental reconstruction.

Disclosure: Ochiai reports he is a paid consultant for Breg and for Conmed Linvatec; he received IP royalties from Smith & Nephew and has stock or stock options with Tenex Health.