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Hip Labral Reconstruction Journal of Hip Preservation Surgery Vol. 0, No. 0, pp. 1–9 doi: 10.1093/jhps/hnz008 Research article Hip labral reconstruction: consensus study Downloaded from https://academic.oup.com/jhps/advance-article-abstract/doi/10.1093/jhps/hnz008/5368134 by Benjamin Domb on 05 March 2019 on indications, graft type and technique among high-volume surgeons David R. Maldonado, Ajay C. Lall, Rafael Walker-Santiago, Philip Rosinsky, Jacob Shapira, Jeffrey W. Chen and Benjamin G. Domb* American Hip Institute, 999 E Touhy Ave, Des Plaines, IL 60018, USA. *Correspondence to: B. G. Domb. E-mail: [email protected] Submitted 21 September 2018; Revised 7 December 2018; revised version accepted 3 February 2019 ABSTRACT To survey high-volume hip arthroscopists regarding their current indications for labral reconstruction, graft preference and technique. In May 2018, a cross-sectional based survey was conducted on high-volume hip arthroscopists. A high-volume surgeon was defined as an orthopaedist who had case experience ranging from 50 to 5000 hip arthroscopies performed annually. The survey included their current indications for labral recon- struction, graft preference and technique. Twelve high-volume surgeons successfully completed the questionnaire. The mean arthroscopic procedures performed by the surgeons annually was 188.7 (range 60–350). Four surgeons (33.3%) performed <5 labral reconstruction cases per year, three (25.0%) 5–10 cases per year, two (16.7%) 11–15 cases per year and three (25.0%) over 20 cases per year. Of the 12 surgeons, 11 (91.6%) would reconstruct in certain primary settings and 100% would reconstruct in revision settings. In the primary setting, the main indi- cations for reconstruction were poor quality labral tissue, calcified labrum and hypoplastic labrum. None of the surgeons recommended labral reconstruction for reparable labral tears in primary cases. In primary cases of irrep- arable labra, 58.3% of the surgeons favoured reconstruction over debridement. In revisions, 100% of the surgeon favoured reconstruction over debridement; 91.7% chose an allograft option versus an autograft alternative. Amongst high-volume arthroscopists, labral reconstruction was considered a valuable technique to restore labral function. Labral reconstruction was more often advocated in revision than in primary settings. Allograft was the preferred choice for reconstruction. Excision of the labral tissue prior to reconstruction was favoured over aug- mentation. Fewer surgeons performed circumferential reconstruction than segmental reconstruction. INTRODUCTION circumstances when labral tears cannot be repaired The labrum is a vital structure for normal biomechanics of (Fig. 1), and labral reconstruction is an alternative tech- the hip joint [1–6]. Preservation and restoration of labral nique to re-establish labral functionality [21–23]. Different function have been advocated as key factors for success in authors have published early outcomes that affirm recon- hip preservation surgery. Several publications demon- struction’s utility [23–26]. However, the ideal technique, strated that hip arthroscopy is a valid tool to accomplish the optimal graft and even proper indications for proced- these goals [7–12]. Labral repair versus debridement may ure remain subjects of debate [22, 27–31]. Both, autograft lead to better results in the short- and mid-long-term out- and allograft have been used for labral reconstruction [22], comes especially in a high-risk population like ‘borderline’ going from iliotibial band [32, 33], indirect head of the rec- dysplastic patients [8, 13–19]. The modernization and ex- tus femoris [21] and hamstring autografts [26], to iliotibial plosion of innovative hip arthroscopy tools and techniques band [25, 30, 34] and hamstring allografts [31, 35]. have shifted the field towards labral preservation proce- Technically demanding, labral reconstructions currently dures over simple debridement [14, 20]. Nevertheless, in can only be accomplished reproducibly by a handful of VC The Author(s) 2019. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact [email protected] 1 2 D. R. Maldonado et al. (D.R.M. and B.G.D.) developed the current study in con- sultation with the Institution Statistics Department. Because the current study only represented the prevalence of reconstruction among high-volume practices, statisti- cians agreed that statistical analysis would not be appropri- ate for the study’s purposes. Downloaded from https://academic.oup.com/jhps/advance-article-abstract/doi/10.1093/jhps/hnz008/5368134 by Benjamin Domb on 05 March 2019 RESULTS Arthroscopic labral reconstruction as an option In total, 21 high-volume hip specialist orthopaedic sur- geons were present at the meeting and invited to partici- pate in the consensus, and 13 surgeons responded to the questionnaire. Of the 13, 12 (92.3%) had labral reconstruc- Fig. 1. Irreparable labral tear. Right hip, viewing from anterolat- tions in their surgical repertoire. High-volume surgeons eral portal with 70 arthroscope, probe coming from the mid-an- that did not include labral reconstruction in their current terior portal. L, labral tear; F, femoral head; *, probe. practice were excluded from the study. The mean total number of hip arthroscopies performed by the surgeons orthopaedic hip surgeons around the world [22, 30, annually was 188.7 (range 60–350). 36–39]. The purpose of this study was to survey these high-volume hip arthroscopists to document their current indications for labral reconstruction, technique and graft Arthroscopic labral reconstructions performed annually preference (allograft versus autograft) [31, 32, 35, 38]. It Each surgeon was asked to report the average number of was hypothesized that labral reconstruction in the setting labral reconstructions they performed per year. Responses of irreparable tears would be an important resource of indicated 33.3% of the surgeons performed <5 reconstruc- treatment among high-volume hip specialist orthopaedic tions per year, 25% between 5 and 10, 16.7% between 11 surgeons. and 15 and 25% performed 20 or more. Labral reconstruction in primary hip arthroscopy MATERIALS AND METHODS Percentages of labral reconstructions in the primary setting In May 2018, a cross-sectional based survey questionnaire were collected. All but one of the surgeons (91.7%) per- was conducted on hip specialist orthopaedic surgeons clas- formed reconstruction in <5% of primary cases (Table I). sified as ‘high-volume surgeons’ who served as faculty members during a Hip Arthroscopy Current Concepts meeting [40–43]. Based on previous high-volume hip arth- Labral reconstruction in revision hip arthroscopy roscopy surgeon consensus, high volume was defined as an Surgeons reported the occurrence of labral reconstruction orthopaedic surgeon who had case experience ranging in the revision setting. In total, 33.3% of the surgeons from 50 to 5000 hip arthroscopies performed annually [43, reported encountering 5–10 cases of reconstruction in 44]. The questionnaire itself was not a validated question- such setting, 25% reported 11–20 cases, 33.3% reported naire. Rather it represented a list of commonly debated 21–40 cases and 8.3% reported 41 or more cases per year, questions within the hip arthroscopy community concern- (Table I). ing arthroscopic labral reconstruction. The survey included four fill in the blank questions, six single-choice questions Indications for labral reconstruction and two multiple-choice questions (Appendix). The partic- The following were selected as indications for labral recon- ipants completed their surveys in person, and responses struction in a primary case: poor quality labral tissue were kept anonymous. Questions were designed to include (21.1%), calcified labrum (26.3%) and hypoplastic labrum each respondent’s current indications, graft type preference (7.9%). No surgeon selected ‘torn labrum’ as an indication and technique for labral reconstruction. for labral reconstruction (Table II). The study was exempt from institutional review board Revision arthroscopy for failed prior labral repair or because of the confidential and anonymous nature of the prior reconstruction was another selection for indications survey. Consent from each individual surgeon was for labral reconstruction (26.3% and 18.4%, respectively) obtained before participation. The lead and senior authors (Table II). Labral reconstruction survey 3 Table I. Labral reconstruction frequency Table II. Surgical indications and irreparable labra Surgeons (%) procedures Reconstructions performed annually Percentage 5 cases per year 4 (33.3) Indications for reconstruction Downloaded from https://academic.oup.com/jhps/advance-article-abstract/doi/10.1093/jhps/hnz008/5368134 by Benjamin Domb on 05 March 2019 5–10 cases per year 3 (25.0) Poor quality labral tissue in primary 66.6% surgery 11–15 cases per year 2 (16.7) Calcified labrum in primary surgery 83.3% 20 cases per year 3 (25.0) Hypoplastic labrum in primary surgery 4 (33.3%) Percentage of primary arthroscopies with reconstruction (%) ALL primary surgeries for torn labrum 0 0 1 (8.3) Revision arthroscopy for failed previous 75% failed repair 1 5 (41.7) Revision arthroscopy
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