Abstract
Background:
At the time of hip arthroscopy, some patients are found to have irreparable labral tears that are not amenable to primary repair. For these patients, treatment with segmental reconstruction is a surgical option to restore labral tissue and biomechanics.
Indications:
Patients with segmental irreparable hip labral tears that are technically not amenable for primary labral repair should be considered for labral reconstruction with allograft.
Technique Description:
Standard hip arthroscopic portals are established. An interportal capsulotomy is performed, and acetabular rim trimming is performed to remove the pincer deformity. Visualized segmental labral defects are measured using a piece of suture to allow for measurement of a curved surface and 1.4-mm polyether ether ketone (PEEK) anchors are placed in anticipation of labral fixation. On the back table, the tibialis anterior allograft is prepared for labral reconstruction. We mark a central portion of the graft tissue based on the measured defect size. A 3-0 vicryl suture is used to place a running stitch from one end to the other of the marked portion of the allograft and the marked, prepared graft is sharply divided from the rest of the tissue. Stitches from the anterior and posterior anchors are passed through the graft using a free needle. The graft is then placed through the distal accessory anterolateral portal and positioned into place. The posterolateral and then medial-most anchors are secured and tied using arthroscopic knots, followed by sequential tying of the middle anchors. Any additional arthroscopic procedures, such as cam resection, are performed, and capsular/skin closure is performed using standard methods.
Results:
Published outcomes support reconstruction of the labrum using allograft, with 2 series consisting of a total of 141 segmental/circumferential reconstructions demonstrating similar outcome scores at 2 years of follow-up as compared to matched cases of primary labral repairs.
Discussion/Conclusion:
Hip segmental labral reconstruction with tibialis anterior allograft provides a viable surgical option for patients with labral defects precluding primary labral repair. The presented material demonstrates a readily employable technique as well as clear, step-by-step postoperative rehabilitation protocols, and satisfactory published short- and mid-term outcomes literature.
This is a visual representation of the abstract.
Video Transcript
The following video will focus on arthroscopic hip labral reconstruction, namely the treatment of irreparable labral tears with segmental allograft reconstruction.
The following are our disclosures.
In this video, we will discuss background information regarding hip labral tears, do our case presentation including our preferred surgical technique, then discuss postoperative management, as well as return to sport guidelines, and conclude with published patient-reported outcomes.
Hip labral tears involve tearing of the acetabular labrum and are usually due to underlying pathology and morphology, such as femoroacetabular impingement (FAI) and hip dysplasia. There is a rapidly advancing arthroscopic treatment of hip labral tears. While historically these were initially debrided, these patients now have repair as the standard of care. However, some patients present with irreparable or complex tears that are not amenable to primary repair. This includes patients with ossified labrums, which require near total segmental labral resection given near full width ossific involvement. In addition, some patients present with hypoplastic labrums, often <2 to 4 mm in width, which are incapable of holding a suction seal. For these patients, treatment with segmental reconstruction is a surgical option and will be the focus of the present video.
Our case involves a 38-year-old woman presenting with 8 years of progressive left hip pain, which has become worse over the course of the past 2 months. She has no previous history of hip surgery and has trialed nonsteroidal anti-inflammatory medications, physical therapy, and a corticosteroid injection without substantial sustained benefit. She currently rates her pain at a 7/10 and describes this in a c-shape distribution above her groin.
On physical examination, the patient has an antalgic gait and has a range of motion consisting of full extension, flexion to 100°, external rotation to 20°, and internal rotation to 0°. She has 4+/5 strength in flexion, abduction, and adduction due to pain. She had a positive FADIR (Flexion Adduction and Internal Rotation) test and a painful arc of motion from 1 to 3 o’clock. Radiographs demonstrate labral calcification, as well as a well-preserved joint space with overall Tonnis grade 0 or 1 changes. On the left, the lateral center edge angle measured 50°, consistent with a pincer deformity. The alpha angle measured 63°, consistent with a cam deformity.
Magnetic resonance imaging (MRI) of the left hip was also reviewed, and this demonstrated an acetabular labral tear and reconfirmed the patient’s FAI, as well as labral calcification. There was no evidence of cartilage degeneration, stress fracture, avascular necrosis (AVN), or surrounding muscle tendon tears.
Given no substantial improvements with conservative nonoperative care, the patient wished to proceed with surgery. We will now demonstrate our preferred surgical technique.
Patients undergo general endotracheal anesthesia and are positioned in standard hip arthroscopic fashion, namely the legs are placed in a lower extremity suspension table with a padded perineal post and the bilateral feet placed in traction boots. The field is then draped in standard fashion with fluoroscopy positioned on the contralateral side of the patient, and standard arthroscopic portals are created.
Namely, under fluoroscopic visualization, a standard anterolateral portal is established with needle localization and then used to establish a modified midanterior portal.
Using a modified midanterior viewing portal, an interportal capsulotomy is then performed. The casulolabral recess is subsequently reflected to expose the pincer deformity of the acetabular rim. We perform rim trimming using a 5.5 mm cylindrical burr, starting with an anterolateral viewing portal to prepare the anterior acetabular rim and finishing with a modified midanterior viewing portal to remove the pincer deformity as it extends superiorly. In the present patient, the labral ossification was so extensive that it required a larger capsulotomy extending to the 9 o’clock position from our standard 12 o’clock position. Rim trimming of the ossification extended from 3 to 9 o’clock. Given the segmental labral defect resulting from the extensive labral ossification, we proceeded with preparation for segmental reconstruction. We placed our first anchor on the lateral-most extent of the labral tear with our arthroscope in the mid-anterior portal and the drill guide in the anterolateral portal. The defect was measured using a piece of suture from the anchor which was placed along the acetabular rim in order to measure a curved surface. We then proceeded with placing our additional anchors for labral fixation. As we moved medially, the arthroscope was placed in the anterolateral portal and a distal anterolateral accessory portal was employed to place anchors along the medial acetabular rim. A total of 6 1.4-mm poly(aryl-ether-ether-ketone) (PEEK) suture anchors were placed in preparation for labral reconstruction. Having placed our anchors and provided measurements for graft preparation, we then removed traction and proceed with our cam decompression while graft preparation was completed on the back table.
On the back table, the tibialis anterior allograft was prepared for labral reconstruction. This is begun in parallel to anchor placement for labral reconstruction in order to lessen operative time. For graft preparation, we mark a central 65-mm portion of the healthy and tubular aspect of the graft based on the measured size of our defect. A 3-0 vicryl suture is then used to place a running stitch from one end to the other of the marked portion of the allograft. The prepared central portion of the allograft is then sharply divided from the rest of the graft using a scalpel and the ends are ensured to be satisfactorily tapered for subsequent passing.
From the 2 sliding suture tails from the anterior and posterior anchors, one of each is brought out through a cannulated distal anterolateral accessory portal and passed through the graft using a free needle. The other end of each suture is pulled through the anterolateral portal, which is then used as a viewing portal. With traction resumed, the graft is then placed through the distal anterolateral accessory portal and cannula using the Kite technique as previously described by Bhatia and colleagues and the graft is positioned into place, using the medial- and lateral-most anchors as 2 guidewires to pull the ends of the graft into place until it comes adjacent to the intact native labrum. The posterolateral anchor is secured and tied using arthroscopic knots. The medial-most anchor is then used to tie down the medial-most aspect of the graft through the mid-anterior portal. Subsequently, the middle anchors are then used to tie down the middle aspect of the graft and the other anchors are sequentially tied to completion. Upon completion, the graft was noted to provide excellent recreation of the labrum.
Having completed our labral reconstruction as well as our cam and pincer resections, capsular plication was then performed using a suture shuttling device and high tensile strength polyethylene sutures. Wounds are then closed with 3.0 vicryl in the subcutaneous tissue and 2.0 prolene in the skin. A postoperative brace is applied.
In terms of complications, tips, and tricks, we would like to highlight the importance of meticulous graft measurement and preparation. It is important to use the tubularized portion of the tibialis anterior graft, avoid frayed ends and edges as these may get caught up during passage, and also to slightly taper the graft ends to ease passage. In addition, one should ensure that the guidewire sutures from the medial and lateral-most anchors are not crossed prior to introduction into the joint to avoid suture and graft entanglement. Finally, keep graft passage sutures tight at all times to avoid the graft blowing up within the joint.
Postoperative rehabilitation consists of 4 distinct phases. Phase 1 focuses on foot flat weight-bearing restrictions with the goal to protect the joint and avoid irritation. For the first 3 postoperative weeks, we limit hip flexion to 0 to 90° and abduction to 0 to 30°, taking care to avoid hip extension. Phase 2 has increased weight-bearing and gait patterning with the goal of noncompensatory gait and progression. Phase 3 focuses on functional exercises with the goal of returning the patient to their pre-injury level.
Return to sport is considered phase 4. Patients perform a running analysis and functional sports assessment prior to returning to running, cutting, and agility activities. We evaluate dynamic neuromuscular control with multiplane activities and patients must be pain and swelling free prior to returning to sport. In addition, they must have less than 10% deficit on their functional testing profile as compared to the contralateral side. Our patients return to sport typically at 4 to 6 months postoperatively, although this can extend to a year depending on their postoperative rehabilitation.
Published outcomes support reconstruction of the labrum using allograft. Bodendorfer et al in their 2021 publication examined 104 hips undergoing reconstruction with iliotibial band, hamstrings, and other grafts included. They matched these to 312 primary labral repairs and found comparable improvements in modified Harris Hip scores, Health Outcomes Survey activities of daily living, as well as sports-specific subscale, International Hip Outcome Tool, and visual analog scale as compared with primary labral repairs. Similarly, Domb et al in their 2020 publication evaluated 37 hips undergoing circumferential reconstruction with tibialis anterior allograft. They matched these to 111 primary labral repairs and similar to Bodendorfer et al found comparable improvements in their patient-reported outcomes when comparing their reconstruction patients with their primary labral repairs.
The following are the references included in our presentation.
We thank you for your time and attention.
Footnotes
Submitted October 20, 2021; accepted February 8, 2022.
One or more of the authors has declared the following potential conflict of interest or source of funding: S.J.N. received non-financial support from Allosource, Arthrex Inc., Athletico, DJ Orthopaedics, Linvatec, Miomed, and Smith & Nephew; and personal fees from Ossur, Springer, and Stryker. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
