Acetabular Labral Tears Research Articles

Two-Year Outcomes of Primary Arthroscopic Surgery in Patients with Femoroacetabular Impingement: A Comparative Study of Labral Repair and Labral Reconstruction.

Labral repair has become the preferred method for the arthroscopic treatment of acetabular labral tears that are associated with femoroacetabular impingement (FAI) resulting in pain and dysfunction. Labral reconstruction is performed mainly in revision hip arthroscopy but can be utilized in the primary setting for absent or calcified labra. The purpose of this study was to compare the minimum 2-year patient-reported outcomes (PROs) and risk of revision or conversion to arthroplasty between primary labral reconstruction and primary labral repair. Patients with FAI who underwent primary hip arthroscopy with labral repair or reconstruction performed by the senior author between 2006 and 2018 were identified from a prospectively enrolled patient outcome registry. Exclusion criteria included confounding injuries, dysplasia, prior ipsilateral hip surgery, or a joint space of <2 mm. Patients who were 18 to 80 years old were eligible for inclusion. Multiple regression with inverse propensity score weighting was conducted to estimate the average treatment effect in the treated (ATT) for labral reconstruction versus labral repair with respect to postoperative PROs and the likelihood of subsequent surgery (revision hip arthroscopy or conversion to arthroplasty). PRO end points included the Hip Outcome Score Activities of Daily Living subscale (HOS-ADL), modified Harris hip score, Western Ontario and McMaster Universities Osteoarthritis Index total score (WOMAC), 12-Item Short Form Health Survey Physical Component Summary score (SF-12 PCS), and patient satisfaction. A total of 150 hips undergoing primary labral reconstruction and 998 hips undergoing primary labral repair were included. The median follow-up time was 5.3 years in the reconstruction group and 5.8 years in the repair group. Compared with labral repair, labral reconstruction was associated with a higher risk of conversion to total hip arthroplasty (THA) (20% versus 7%; adjusted odds ratio, 3.2; 95% confidence interval [CI], 1.2 to 8.8; p = 0.024). Inverse propensity score-weighted multiple regression estimated a significant negative effect of labral reconstruction, relative to labral repair, on the postoperative values for the HOS-ADL (ATT, -3.3; 95% CI, -5.8 to -0.7; p = 0.012) and WOMAC (ATT, 2.6; 95% CI, 0.1 to 5.2; p = 0.044). Compared with primary labral reconstruction, primary labral repair resulted in better postoperative HOS-ADL and WOMAC values and decreased conversion to THA. These findings were demonstrated in both the unadjusted group comparisons and multivariable modeling. These data support the use of labral repair in the primary setting of labral tears and the reservation of labral reconstruction for more advanced labral pathology or for revision cases. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Hip Arthroscopy Versus Physical Therapy for the Treatment of Symptomatic Acetabular Labral Tears in Patients Older Than 40 Years: 24-Month Results From a Randomized Controlled Trial

Background: The indications for hip arthroscopy in patients aged ≥40 years remain controversial, as observational studies have suggested that advanced age portends poor functional outcomes, poor durability of improvement, and high rates of conversion to total hip arthroplasty. Purpose: To compare hip arthroscopy versus nonoperative management for symptomatic labral tears in patients aged ≥40 years with limited radiographic osteoarthritis. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: This single-surgeon, parallel randomized controlled trial included patients aged ≥40 years with limited osteoarthritis (Tönnis grades 0-2) who were randomized 1:1 to arthroscopic surgery with postoperative physical therapy (SPT) or physical therapy alone (PTA). Patients who received PTA and achieved unsatisfactory improvement were permitted to cross over to SPT after completing ≥14 weeks of physical therapy (CO). The primary outcomes were the International Hip Outcome Tool-33 score and modified Harris Hip Score at 24 months after surgery, and secondary outcomes included other patient-reported outcome measures and the visual analog scale for pain. The primary analysis was performed on an intention-to-treat basis using linear mixed-effects models. Sensitivity analyses included modified as-treated and treatment-failure analyses. Results: A total of 97 patients were included, with 52 (53.6%) patients in the SPT group and 45 (46.4%) patients in the PTA group. Of the patients who underwent PTA, 32 (71.1%) patients crossed over to arthroscopy at a mean of 5.10 months (SD, 3.3 months) after physical therapy initiation. In both intention-to-treat and modified as-treated analyses, the SPT group displayed superior mean patient-reported outcome measure and pain scores across the study period for nearly all metrics relative to the PTA group. In the treatment-failure analysis, the SPT and CO groups showed greater improvement across all metrics compared with PTA; however, post hoc analyses revealed no significant differences in improvement between the SPT and CO groups. No significant differences were observed between groups in rates of total hip arthroplasty conversion. Conclusion: In patients ≥40 years of age with limited osteoarthritis, hip arthroscopy with postoperative physical therapy led to better outcomes than PTA at a 24-month follow-up. However, additional preoperative physical therapy did not compromise surgical outcomes and allowed some patients to avoid surgery. When surgery is indicated, age ≥40 years should not be considered an independent contraindication to arthroscopic acetabular labral repair. Registration: NCT03909178 (ClinicalTrials.gov identifier).

Females with hip pain walk with altered kinematics at peaks and throughout the gait cycle

BackgroundFemales with acetabular dysplasia and/or labral tears (hip pain) exhibit altered walking kinematics, with studies reporting mixed results in sagittal and frontal planes compared to pain-free controls, often conducting only discrete analyses and warranting further investigation. The objective of this study was to investigate discrete and continuous hip and pelvic kinematics between females with and without hip pain in two walking conditions. MethodsWe collected kinematic walking data from 69 females (35 with hip pain, 34 controls) using motion capture and an instrumented treadmill in two conditions: preferred and fast (125% preferred). We used a general linear model and one-dimensional statistical parametric mapping to conduct discrete and continuous analyses comparing kinematics between groups, with and without adjustment for gait speed. FindingsThe hip pain group walked with reduced peak hip extension (Preferred: P = .046, Cohen's d = 0.41; Fast: P = .028, d = 0.48) and greater peak anterior pelvic tilt (Preferred: P = .011, d = 0.57; Fast: P = .012, d = 0.58) compared to controls. From continuous analyses, the hip pain group walked with reduced hip extension during terminal stance (Fast: P = .040), greater anterior pelvic tilt throughout (Preferred: P = .007; Fast: P = .004), and greater contralateral pelvic drop (Preferred: P = .045) during midstance. Adjusting for speed slightly affected p-values, but significance was retained for all prior variables except pelvic drop. InterpretationKinematic differences between individuals with and without hip pain may provide insight into potential predisposing factors for hip pathology and/or compensations for pain or pathological processes. This work furthers understanding of altered movement patterns in individuals with hip pain and may inform physical therapy treatments.

Association Between Severity of Chondrolabral Junction Breakdown and Functional Outcomes After Hip Arthroscopy for Acetabular Labral Tears

Background: Despite focus on surgical preservation of the chondrolabral junction (CLJ), the transition zone between the acetabular cartilage and labrum, the association between severity of CLJ breakdown and functional outcomes after hip arthroscopy remains unexplored. Purpose: To assess the influence of CLJ breakdown on patient-reported outcome measures (PROMs) at a 24-month follow-up after hip arthroscopy for symptomatic labral tears. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review of prospectively collected data was conducted to identify patients ≥18 years of age with a minimum 24-month follow-up who underwent hip arthroscopy by a single surgeon for the treatment of symptomatic labral tears secondary to femoroacetabular impingement. The Beck classification of transition zone cartilage was used to grade CLJ damage; patients with grades 0 to 2 were stratified into the mild CLJ damage cohort, and those with grades 3 and 4 were stratified into the severe CLJ damage cohort. PROMs were collected at baseline and at 3, 6, 12 months, and annually thereafter postoperatively. Linear mixed-effects models were used to compare PROMs. Rates of achieving clinically meaningful thresholds and subsequent surgery rates were also compared. Results: In total, 198 patients met the inclusion criteria, with a mean follow-up of 3.54 ± 1.26 years. A total of 95 patients with severe CLJ damage (mean age, 34.9 ± 10.5 years) were compared with 103 patients with mild CLJ damage (mean age, 38.2 ± 11.9 years). Hip Outcome Score–Activities of Daily Living (HOS-ADL), Non-Arthritic Hip Score (NAHS), and visual analog score for pain were inferior in the severe CLJ group at enrollment and all follow-up time points (P≤ .05). However, patients with severe CLJ breakdown exhibited greater improvements in HOS-ADL and NAHS at the 24-month follow-up and achieved clinically meaningful thresholds at equivalent rates to patients with mild CLJ breakdown. Subsequent surgery rates were 6.8% and 12.6% in patients with mild versus severe CLJ damage, respectively (P = .250). Conclusion: Severe CLJ breakdown is associated with increased pain and decreased functional level preoperatively and up to 24 months after hip arthroscopy. Despite this, patients with severe CLJ breakdown experienced greater improvements in functional outcomes at a 24-month follow-up and achieved clinical thresholds at similar rates to patients with mild CLJ damage. Thus, while worse baseline pain and functional levels may indicate severe CLJ breakdown, these patients still benefit substantially from hip arthroscopy.

Analysis of Hip Preservation Questions on the Orthopaedic In-Training Examination Over the Past 20 Years.

The orthopaedic in-training examination (OITE) is a 275-question test for orthopaedic residents administered annually. As the field of orthopaedics changes, the OITE evolves its content. The incidence of hip preservation-related procedures has increased substantially over the past decade; nonetheless, an analysis of the trends of hip preservation questions on the OITE has not yet been performed. The purpose of the study was to evaluate the number and type of questions on the OITE related to hip preservation to determine whether trends over time paralleled the increases in hip-related care in clinical practice. It was hypothesized that the frequency of hip preservation questions on the OITE would increase with time. Cross-sectional study. Each OITE between 2002 and 2021 was reviewed for questions related to hip preservation. The types of questions included under "hip preservation" were those related to femoroacetabular impingement (FAI), athletic soft tissue injuries of the hip, acetabular labral tears, hip arthroscopy, and surgical management of adult hip dysplasia-excluding arthroplasty. Questions were quantified and categorized by topic, taxonomy level, associated imaging, and cited sources. There were 30 hip preservation-related questions between 2002 and 2021. Of these, 77% occurred within the past 10 years. Also, 14 questions (47%) had associated images in the question stem-the most common being radiographs (n = 8 questions). The most commonly tested subcategories were FAI (n = 11 questions [37%]), athletic injuries (n = 7 questions [23%]), and anatomy (n = 7 questions [23%]). Over the last 10 years, 97.9% of citations were from journal articles-the most common being the Journal of the American Academy of Orthopaedic Surgeons, Clinical Orthopedics and Related Research, and the American Journal of Sports Medicine. The frequency of hip preservation-related questions on the OITE has increased with time, reflecting trends in clinical practice.

The Effect of Pelvic Incidence on Outcomes After Hip Arthroscopy for Femoroacetabular Impingement and Acetabular Labral Tears

Background: In the setting of femoroacetabular impingement (FAI), decompression osteoplasties reconcile deleterious loading patterns caused by cam and pincer lesions. However, native variations of spinopelvic sagittal alignment may continue to perpetuate detrimental effects on the labrum, chondrolabral junction, and articular cartilage after hip arthroscopy. Purpose: To evaluate the effect of pelvic incidence (PI) on postoperative outcomes after hip arthroscopy for acetabular labral tears in the setting of FAI. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective query of prospectively collected data identified patients ≥18 years of age who underwent primary hip arthroscopy for FAI and acetabular labral tears between February 2014 and January 2022, with 3-, 6-, 12-, and 24-month follow-ups. Measurements for PI, pelvic tilt (PT), sacral slope (SS), and acetabular version were obtained via advanced diagnostic imaging. Patients were stratified into low-PI (<45°), moderate-PI (45°≤ PI ≤ 60°), and high-PI (>60°) cohorts. Patient-reported outcome measures (PROMs), clinically meaningful outcomes (ie, minimal clinically important difference, Patient Acceptable Symptom State, substantial clinical benefit, and maximal outcome improvement), visual analog scale (VAS) pain scores, and patient satisfaction were compared across cohorts. Results: A total of 74 patients met eligibility criteria and were stratified into low-PI (n = 28), moderate-PI (n = 31), and high-PI (n = 15) cohorts. Correspondingly, patients with high PI displayed significantly greater values for PT (P = .001), SS (P < .001), acetabular version (P < .001), and acetabular inclination (P = .049). By the 12- and 24-month follow-ups, the high-PI cohort was found to have significantly inferior PROMs, VAS pain scores, rates of clinically meaningful outcome achievement, and satisfaction relative to patients with moderate and/or low PI. No significant differences were found between cohorts regarding rates of revision arthroscopy, subsequent spine surgery, or conversion to total hip arthroplasty. Conclusion: After hip arthroscopy, patients with a high PI (>60°) exhibited inferior PROMs, rates of achieving clinically meaningful thresholds, and satisfaction at 12 and 24 months relative to patients with low or moderate PI. Conversely, the outcomes of patients with low PI (<45°) were found to match the trajectory of those with a neutral spinopelvic alignment (45°≤ PI ≤ 60°). These findings highlight the importance of analyzing spinopelvic parameters preoperatively to prognosticate outcomes before hip arthroscopy for acetabular labral tears and FAI.

The Effect of Pelvic Incidence on Outcomes Following Hip Arthroscopy for Femoroacetabular Impingement and Acetabular Labral Tears

Objectives: Left untreated, femoroacetabular impingement (FAI) poses an elevated risk for the early progression of degenerative joint disease. As a result, the utilization of hip arthroscopy has increased to counteract the maladaptive effects of FAI, as femoroacetabular osteoplasties have been shown to reconcile deleterious loading patterns caused by CAM and pincer lesions. However, variations in the sagittal alignment of the lumbosacral spine also pose an elevated risk for the early progression of degenerative joint disease. While femoroacetabular osteoplasties improve degenerative loading patterns caused by CAM and pincer lesions, variations in the sagittal alignment of the lumbosacral spine may continue to generate deleterious effects on the labrum, chondrolabral junction, and articular cartilage following hip arthroscopy for acetabular labral tears and FAI. Thus, the purpose of this study was to evaluate the impact of pelvic incidence (PI) on patient-reported outcomes measures (PROMs) and rates of achieving clinically meaningful outcomes following primary hip arthroscopy for acetabular labral tears and FAI. Methods: A retrospective review of a prospectively collected, single-surgeon database was performed to identify patients ≥18 years of age who underwent primary hip arthroscopy for the treatment of labral tears secondary to FAI with a minimum of 12 months of follow-up. Patients with a history of ipsilateral hip or spine surgery, absence of preoperative lumbar spine imaging, radiographic evidence of hip dysplasia or advanced hip osteoarthritis, and contraindicated spinal pathologies were excluded. PI, pelvic tilt (PT), sacral slope (SS), and acetabular version were measured on 2-D supine lumbar images, and patients were stratified into low PI (PI &lt; 45°), moderate PI (45° ≤ PI ≤ 60°), and high PI (PI &gt; 60°) cohorts. PROMs, VAS Pain, and frequencies of achieving clinically meaningful outcomes were compared between groups. PROMs and frequencies of achieving clinically meaningful outcomes were compared between cohorts using one-way analysis of variance tests and Fisher’s exact tests, respectively. Additionally, a sensitivity analysis using a linear mixed-effects model with time as a continuous variable was carried out to evaluate the weighted differences in PROM averages between cohorts. Results: A total of 74 patients undergoing primary hip arthroscopy for FAI and acetabular labral tears met eligibility criteria and were subsequently stratified into low ( n=28), moderate ( n=31), and high ( n=15) PI cohorts. The mean ± SD length of follow-up was 25.16 ± 2.91 months, and no significant differences were observed between cohorts in patient demographics. However, as expected, patients in the high PI cohort displayed significantly larger mean values for PT ( P=0.001), SS ( P&lt;0.001), acetabular version ( P&lt;.001), and acetabular inclination ( P=0.049). Moreover, despite no differences in preoperative outcome scores between cohorts, the high PI cohort displayed significantly inferior scores for all PROMs and VAS pain across 6-, 12, and 24-month follow-ups. This finding also extended to our sensitivity analysis, with the high PI cohort displaying significantly lower weighted averages in scores across all PROMs relative to the moderate PI cohort ( P≤.001 for all). Additionally, the high PI cohort demonstrated significantly lower rates of clinically meaningful outcome achievement and overall patient satisfaction at 12- and 24-month follow-ups compared to the moderate and/or low PI cohorts. No significant differences were found between cohorts in terms of revision hip arthroscopy, subsequent spine surgery, or conversion to THA. Conclusions: Following hip arthroscopy to address acetabular labral tears, patients with a high PI exhibit significantly inferior PROMs relative to those with moderate and low PI. Thus, despite addressing FAI deformities, variations in lumbosacral alignment may continue to impact patient outcomes. Although the current study design limits our ability to infer causality, the significantly greater acetabular version and inclination values observed in the high PI cohort lead us to speculate that the sagittal imbalance in the setting of a high PI places increased mechanical stress on the anterior-superior acetabulum, which portends poor outcomes following hip arthroscopy. Overall, our findings highlight the critical importance of analyzing pelvic alignment in order to prognosticate outcomes following hip arthroscopy for acetabular labral tears in the setting of FAI.

Portal Placement for Hip Arthroscopy

Hip arthroscopy is a well-established technique that has become a mainstay in the repair of bony and ligamentous injuries when conservative methods fail to return adequate joint mobility and function. The technique has both diagnostic and therapeutic utility and its use as a minimally invasive orthopedic surgery continues to advance. Several studies have suggested that arthroscopic surgical management has more favorable outcomes in certain circumstances when compared to hip-specific conservative measures. The approach to establishing adequate sites for portal placement is dependent upon recognizing the pertinent anatomy of the surgical site. At the same time, the operator must be mindful of the desired views once access to the joint space has been obtained. Proper visualization of the desired joint region is critical to reducing the conversion into inherently riskier total hip arthroplasties (THAs). Additionally, the neurovascular landscape of the groin presents technical challenges with the procedural approach that requires significant skill to avoid injuring vital structures in the area. Acetabular labral tears are frequently repaired with this type of operative management as techniques and approaches become more refined. Here, we present the case of a 24-year-old female who is undergoing an arthroscopic anterior labral repair, highlighting both the anatomical landmarks and the access points for portal placement used in the procedure.

Isolated Arthroscopic Debridement of Acetabular Labral Tears: High Rates of Failure and Conversion to Total Hip Arthroplasty at 13-Year Minimum Follow-up

Background: Historically, symptomatic hip labral lesions were treated with arthroscopic debridement. Hip labral repair has become the standard treatment for labral pathology; however, to date, there are limited long-term studies regarding the outcomes of isolated labral debridement. Purpose: To (1) evaluate the long-term patient-reported outcomes of isolated labral debridement, (2) report reoperation and arthroplasty rates, and (3) identify risk factors contributing to reoperation or poor clinical outcomes. Study Design: Case series; Level of evidence, 4 Methods: A retrospective review of a prospectively generated cohort of 59 hips in 57 patients from 1996 to 2010 who underwent hip arthroscopy with labral debridement was performed. Only patients with Tönnis grade <3 were included. Additionally, given the time period analyzed, resection of cam morphology was not performed, and the interportal capsulotomy was not repaired. The pre- and postoperative modified Harris Hip Score; Hip Outcome Score (HOS)-Activities of Daily Living and -Sports scores; and reoperation, conversion to total hip arthroplasty, and risk factors were analyzed. Results: In total, 48 hips in 47 patients (14 men, 33 women; mean age, 48.0 ± 12.9 years) met inclusion criteria and were followed for a mean of 17 ± 3 years (range, 13-27 years). The mean preoperative Tönnis grade was 1.3 ± 0.6 (range, 0-2), the mean chondral acetabular International Cartilage Regeneration & Joint Preservation Society (ICRS) grade was 1.7 ± 1.6 (range, 0-4), the mean chondral femoral ICRS grade was 0.9 ± 1.4, and the mean acetabular labral articular cartilage grade was 2.5 ± 1.2 (range, 0-4). At the final follow-up, mean the modified Harris Hip Score, HOS-Activities of Daily Living score, and HOS-Sports score were 82.2 ± 16.6, 81.9 ± 20.5, and 82.2 ± 20.5, respectively. Nineteen hips underwent subsequent reoperation at a mean of 5.5 ± 6.2 years (range, 0.5-21.2 years) postoperatively, including 16 hips (33% overall) being converted to total hip arthroplasty. Higher acetabular ICRS chondral grades at the time of surgery were observed in patients who went on to subsequent surgery compared with those who did not (2.3 ± 1.6 vs 1.1 ± 1.5; P = .02). In reoperation-free hips, Tönnis grade demonstrated a trend of increasing over time (1.4 preoperatively vs 1.7 at radiographic follow-up; P = .08). At the final follow-up, 19 hips (40%) had undergone reoperation, and 5 additional hips (10%) were rated as “abnormal” or “severely abnormal” in function, resulting in an overall clinical failure rate of 50%. Conclusion: Isolated labral debridement was found to result in high rates of failure and reoperation, with a third of patients being converted to arthroplasty and half of patients meeting criteria for reoperation or clinical failure. Of note, for patients remaining reoperation-free, satisfactory outcome scores were observed.

Arthroscopic classification in comprehensive diagnosis of avascular necrosis of femoral head

The paper proposes and substantiates an arthroscopic classification of pathological processes in the hip joint associated with avascular necrosis of the femoral head (ANFH). In 2018–2022, the authors developed and advanced to the clinic “Method of minimally invasive two-stage decompression with bone alloplasty” (RF patent No. 2691543), which involved diagnostic and therapeutic arthroscopy of the hip joint as its first stage. The international ARCO classification (Association Research Circulation Osseous classification) was chosen as the prototype for the invention. The endoscopic view was recorded and compared with the data of radiological research methods (radiography, spiral CT and MRI). The revealed changes are characterized by the absence of pronounced pathological signs at stages 0, I according to ARCO, which testifies to the possibility of arthroscopic intervention only for the purpose of joint cavity drainage. Further development of necrosis is accompanied by the formation of cartilage flaps, cartilage defects, acetabular labrum tears, lysis of the ligament of the femoral head with the subsequent development of arthrosis, and, therefore, requires a combined approach.

Comparative analysis between operative and non-operative acetabular labral tear injuries in division 1 collegiate athletes

Acetabular labral tears have shown to be difficult to diagnose and manage in an active and competitive athletic population. The goal of this study was to compare NCAA Division 1 collegiate athletes undergoing operative and non-operative management of their labral injuries by assessing ability to return to competition and secondarily evaluate days lost from sport. A retrospective cohort analysis was conducted on Division 1 collegiate athletes from 2005 to 2020, incorporating all varsity university sports. Records showing MRI confirmed diagnosis were included in the cohort, as well as all pertinent clinical data. Data revealed 10/18 (55%) of individuals managed conservatively versus 23/29 (79%) surgically (p-value = 0.0834) were able to return to sport following treatment. Of those athletes, 22 surgical patients experienced a mean of 324 days ± 223 days lost from sport and nine conservatively managed patients experienced a mean of 27 days ± 70 lost days (p-value < 0.001) Seven of nine conservatively managed patients were able to continue competition while undergoing treatment. Findings suggest no statistical significance regarding operative vs non-operative management of acetabular labral tears. The majority of athletes returning to sport and treated conservatively were able to resume competition during treatment. Therefore, treatment of these injuries should be individualized based on athlete’s symptoms.

Hip Arthroscopy in Adolescents Through an Extra-Capsular Approach

Hip arthroscopic treatment for femoroacetabular impingement syndrome and labral tears is the gold standard in the adult and adolescent population, as we all know the most common surgical approach to the hip is entering the central compartment with fluoroscopy and with continuous distraction. A periportal capsulotomy in traction must be done to have visibility and instrument maneuverability. These maneuvers avoid scuffing the femoral head cartilage. In adolescents, extreme care must be taken in hip distraction, as the force used can cause iatrogenic neurovascular lesions, avascular necrosis, and lacerations of the genitals and foot/ankle. Experienced surgeons around the world have developed an extracapsular approach to the hip with smaller capsulotomies with a low complication rate. This approach to the hip has brought attention in the adolescent population because it is more secure and simple. Less force of distraction is needed because the capsulotomy is done first. This surgical technique allows observation of the cam morphology while entering to the hip without distraction. We describe an extracapsular approach as an option to treat femoral acetabular impingement syndrome and labral tears in the pediatric and adolescent population.

What is the Rate of Response to Nonoperative Treatment for Hip-Related Pain? A Systematic Review With Meta-analysis.

OBJECTIVE: We aimed to (1) determine the rate of satisfactory response to nonoperative treatment for nonarthritic hip-related pain, and (2) evaluate the specific effect of various elements of physical therapy and nonoperative treatment options aside from physical therapy. DESIGN: Systematic review with meta-analysis. LITERATURE SEARCH: We searched 7 databases and reference lists of eligible studies from their inception to February 2022. STUDY SELECTION CRITERIA: We included randomized controlled trials and prospective cohort studies that compared a nonoperative management protocol to any other treatment for patients with femoroacetabular impingement syndrome, acetabular dysplasia, acetabular labral tear, and/or nonarthritic hip pain not otherwise specified. DATA SYNTHESIS: We used random-effects meta-analyses, as appropriate. Study quality was assessed using an adapted Downs and Black checklist. Certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach. RESULTS: Twenty-six studies (1153 patients) were eligible for qualitative synthesis, and 16 were included in the meta-analysis. Moderate certainty evidence suggests that the overall response rate to nonoperative treatment was 54% (95% confidence interval: 32%, 76%). The overall mean improvement after physical therapy treatment was 11.3 points (7.6-14.9) on 100-point patient-reported hip symptom measures (low to moderate certainty) and 22.2 points (4.6-39.9) on 100-point pain severity measures (low certainty). No definitive specific effect was observed regarding therapy duration or approach (ie, flexibility exercise, movement pattern training, and/or mobilization) (very low to low certainty). Very low to low certainty evidence supported viscosupplementation, corticosteroid injection, and a supportive brace. CONCLUSION: Over half of patients with nonarthritic hip-related pain reported satisfactory response to nonoperative treatment. However, the essential elements of comprehensive nonoperative treatment remain unclear. J Orthop Sports Phys Ther 2023;53(5):1-21. Epub 9 March 2023. doi:10.2519/jospt.2023.11666.

Diagnostic value of magnetic resonance imaging and magnetic resonance arthrography for assessing acetabular labral tears: A systematic review and meta-analysis.

This study aimed to systematically evaluate the value of magnetic resonance imaging (MRI) and magnetic resonance arthrography (MRA) in the diagnosis of acetabular labral tears. Databases including PubMed, Embase, Cochrane Library, Web of Science, CBM, CNKI, WanFang Data, and VIP were electronically searched to collect relevant studies on magnetic resonance in the diagnosis of acetabular labral tears from inception to September 1, 2021. Two reviewers independently screened the literature, extracted data, and assessed the risk of bias in the included studies by using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. RevMan 5.3, Meta Disc 1.4, and Stata SE 15.0 were used to investigate the diagnostic value of magnetic resonance in patients with acetabular labral tears. A total of 29 articles were included, involving 1385 participants and 1367 hips. The results of the meta-analysis showed that the pooled sensitivity, pooled specificity, pooled positive likelihood ratio, pooled negative likelihood ratio, pooled diagnostic odds ratio, area under the curve of the summary receiver operating characteristic, and Q* of MRI for diagnosing acetabular labral tears were 0.77 (95% confidence interval [CI], 0.75-0.80), 0.74 (95% CI, 0.68-0.80), 2.19 (95% CI, 1.76-2.73), 0.48 (95% CI, 0.36-0.65), 4.86 (95% CI, 3.44-6.86), 0.75, and 0.69, respectively. The pooled sensitivity, pooled specificity, pooled positive likelihood ratio, pooled negative likelihood ratio, pooled diagnostic odds ratio, area under the curve of the summary receiver operating characteristic, and Q* of MRA for diagnosing acetabular labral tears were 0.87 (95% CI, 0.84-0.89), 0.64 (95% CI, 0.57-0.71), 2.23 (95% CI, 1.57-3.16), 0.21 (95% CI, 0.16-0.27), 10.47 (95% CI, 7.09-15.48), 0.89, and 0.82, respectively. MRI has high diagnostic efficacy for acetabular labral tears, and MRA has even higher diagnostic efficacy. Due to the limited quality and quantity of the included studies, the above results should be further validated.

Tissue Regrowth and Its Vascularization Through Bone Marrow Stimulation: Microfracture at the Acetabular Rim for Irreparable Labral Tear in a Porcine Model

Background: The treatment of irreparable acetabular labral tear remains a great challenge. Whether fibrocartilage-like tissue can regrow with sufficient volume to fill the labral defect area through bone marrow stimulation remains unknown. Purpose: To characterize the healing process and vascularization course of the regrown tissue after microfracture at the acetabular rim for irreparable labral tears in a porcine model. Study Design: Descriptive laboratory study. Methods: Twelve pigs randomly underwent unilateral microfracture at the acetabular rim after the resection of a 10 mm–long section of labrum from 10 to 1 o’clock. Pigs were randomly sacrificed at 6 and 12 weeks postoperatively. The regrown tissues were harvested for macroscopic evaluation and histologic assessment. The regrown tissue was zoned into 2 halves to observe the vascular distribution: the capsular half (zone I) and the articular half (zone II). Each zone was divided into 2 parts: the peripheral part (IA and IIA) and the part attached to the acetabulum (IB and IIB). Results: At 6 weeks, all regrown tissue was hypotrophic with <50% filling of the labral defect. Fibrochondrocytes were concentrated at the interface between the acetabulum and the regrown tissue. The vascularization was equal among each part within the regrown tissue. As compared with regrown tissue at 12 weeks, proteoglycan and collagen type 1 and 2 were more evident within the regrown tissue at 6 weeks. At 12 weeks, tissue disintegration occurred in all regrown tissue with <25% filling of the labral defect area. The vascular structure could barely be observed, with few fibrochondrocytes found at the area adjacent to the acetabulum. Conclusion: Fibrocartilage-like tissue did regrow with well-distributed vascular ingrowth of each part of the regrown tissue through bone marrow stimulation at the early stage. However, insufficient volume of the regrown tissue led to loss of the hip suction seal and subsequent tissue disintegration. Clinical Relevance: Microfracture at the rim of the acetabulum alone could not restore the morphology and function of the acetabular labrum. Nonetheless, microfracture at the acetabular rim might be a viable adjunct to labral reconstruction, as the well-distributed vascularization through bone marrow stimulation might overcome the obstacle of poor vascular ingrowth of the articular half of the autograft.

Puncture Capsulotomy Technique for Hip Arthroscopy: Midterm Functional Outcomes.

The most common surgical approaches in hip arthroscopy are interportal and T-capsulotomy. However, these methods may introduce capsular instability. Puncture capsulotomy preserves capsuloligamentous integrity by avoiding iatrogenic transection of the iliofemoral capsular ligament. To present minimum 2-year functional outcomes for patients who underwent arthroscopic treatment for acetabular labral tears and concomitant femoroacetabular impingement using the puncture capsulotomy technique. Case series; Level of evidence, 4. The authors conducted a retrospective review of prospectively collected data on patients who underwent arthroscopic acetabular labral tear treatment between December 2013 and May 2019. Included were patients aged ≥18 years who underwent hip arthroscopy by a single surgeon and completed a minimum of 2 years of patient-reported outcome measure (PROM) surveys. Intraoperatively, patients underwent hip arthroscopy via puncture capsulotomy to treat labral tears and any concomitant femoroacetabular impingement. Clinical outcome data consisted of PROMs. A total of 163 hips were included; the mean patient follow-up was 30.4 months (range, 24-60 months; 95% CI, 28.5-32.3 months). Patients had a mean age of 37.9 years (range, 36.1-39.6 years), with a mean body mass index of 25.9 (range, 25.2-26.5). There were significant improvements in mean [95% CI] baseline to final follow-up scores for the 33-Item International Hip Outcome Tool (iHOT-33) (39.6 [36.8-42.4] vs 76.1 [72.7-79.6]), Hip Outcome Score-Activities of Daily Living (70.0 [67.0-73.0] vs 89.3 [87.3-91.3]), modified Harris Hip Score (60.1 [57.9-62.4] vs 84.9 [82.5-87.2]), and Hip Outcome Score-Sports Specific Subscale (41.8 [37.9-45.6] vs 75.7 [71.7-79.7]) (P < .001 for all). Additionally, the mean [95% CI] visual analog scale pain scores were noted to significantly improve throughout the duration of the postoperative period (from 6.3 [5.9-6.7] to 2.2 [1.8-2.6]; P < .001). There were no incidences of infection, avascular necrosis of the femoral head, dislocation/instability, or femoral neck fracture. At the 2-year follow-up, 81.0%, 62.0%, and 58.9% of hips achieved previously published clinically meaningful iHOT-33 thresholds for minimally clinically important difference, Patient Acceptable Symptom Score, and substantial clinical benefit, respectively. Puncture capsulotomy demonstrated significantly improved functional and clinically meaningful outcomes at a minimum 2-year follow-up, along with a minimal complication rate.

Quantitative and Qualitative Ultrasound Evaluation for the Diagnosis of an Anterosuperior Acetabular Labral Tear.

We investigated the diagnostic performance of qualitative and quantitative ultrasound criteria for anterosuperior acetabular labral tears (ALTs). In all, 118 people with ALTs (120 hips; case group) and 31 asymptomatic volunteers (42 hips; control group) at Peking University Third Hospital between August 2018 and November 2019 were consecutively included. The labral cleft, labral heterogeneous echogenicity, labral plump morphology, paralabral cyst and labral focal hyperechoic area were used as the qualitative criteria. The anterosuperior labral cross-section area (CSA) was measured as the quantitative criterion. The diagnostic utility of the quantitative and qualitative criteria were explored with magnetic resonance imaging as the diagnostic gold standard. Labral heterogeneous echogenicity was the most sensitive criterion for diagnosing ALTs (up to 80.00%), and the specificity of diagnosing ALTs with paralabral cysts, labral focal hyperechoic area and subcortical cysts of the femoral head and neck was as high as 90.48%-100%. The labral CSA in the case group was 0.27 cm2 (0.21-0.39 cm2), which was significantly larger compared with the control group (0.18 cm2 [0.14-0.23 cm2]; p < 0.001). The area under the receiver operating characteristic curve was 0.802 for diagnosing ALTs according to the labral CSA. The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of the combined qualitative criteria for diagnosing ALTs were 90.00%, 71.43%, 90.00%, 71.43% and 85.19%, respectively. Labral heterogeneous echogenicity is a sensitive criterion for diagnosing ALTs, and paralabral cysts, labral focal hyperechoic, area and subcortical cysts of the femoral head and neck are specific criteria. The CSA of the anterosuperior acetabular labrum measured by ultrasound can be used as a quantitative criterion to diagnose ALTs. The combination of labral qualitative criteria provides higher sensitivity and accuracy in diagnosing ALTs.

Management of post traumatic posterior acetabular labral tear: a case report

&lt;p&gt;Traumatic acetabular labral tears causing hip instability are rare. Surgical management of posterior labral tear is essential to prevent chronic hip instability and secondary arthritis. We report a 27-year-old female presented following RTA, with posterior hip dislocation along with posterior labral avulsion, managed by surgical repair using suture anchors. Patient had excellent functional outcome at 12 months of follow-up. High index of suspicion for labral injuries is required in patients with posterior hip dislocation and posterior wall fractures. Early surgical repair of torn labrum is must for excellent functional outcome.&lt;/p&gt;

Biomolecules-releasing click chemistry-based bioadhesives for repairing acetabular labrum tears.

Currently, there are no effective clinical or experimental treatments to fully restore the function of the torn acetabular labrum. To fill the gap, here, we report the finding of progenitor cells in labral tissue, which can be recruited and stimulated to repair torn acetabular labral tissue. This study aimed to develop a biomolecule releasing bioadhesive which can speed up labral tissue healing by eliciting autologous labral progenitor cellular responses. A click chemistry-based bioadhesive, capable of releasing biomolecules, was synthesized to exert ~3× adhesion strength compared with fibrin glue. Via the release of platelet-derived growth factor (PDGF), the adhesive was shown to actively recruit and stimulate the proliferation of labral progenitor cells to the tear sites and within the adhesive. Finally, the ability of this biomolecules-releasing adhesive designed to promote labral tissue regeneration was evaluated using discarded human acetabular labrum tissue compared with surgical suture ex vivo. Histological analysis shows that PDGF-releasing bioadhesive yielded significantly more labrum cell responses and extracellular matrix protein (proteoglycan and collagen) production at the tear tissue site than surgical suture controls. The results confirm that the new PDGF-releasing bioadhesive can activate the responses of autologous labral progenitor cells to significantly improve labral tissue regeneration. Clinical significance: These PDGF-releasing bioadhesives may serve as a new and effective tool for repairing and regenerating acetabular labrum tears.

BMP-2 Modified Electrospun Scaffold for Acetabular Labral Reconstruction Promotes Collagen Fiber Regeneration in a Porcine Model

Background: Acetabular labral tear is one of the contributing factors to early hip osteoarthritis. Patients with symptomatic labral tears may require surgical treatment, and labral reconstruction is indicated in cases of irreparable tears. Purpose: The purpose of the study was to construct the bone morphogenic protein 2 (BMP-2) electrospun scaffold for acetabular labral reconstruction and analyze the composition of the labrum and the influence of collagen fiber distribution in regenerated tissue on the biomechanical properties of labrum. Study Design: Controlled laboratory study. Methods: Eighteen mature male miniature pigs were selected for labral reconstruction in vivo. The animals were divided into 3 groups, including the autologous tendon group (T group), dopamine/polylactic acid–polyethylene glycol (PELA) electrospun group (DP group), and dopamine/PELA electrospun/BMP-2 group (DPB group), and the native labra were used as the control group. The microstructure of the reconstructed labrum was analyzed by scanning electron microscopy. Histologic and immunohistochemistry sections were used to evaluate the composition and structure of reconstructed labrum. The related gene expression was tested via quantitative reverse transcriptase–polymerase chain reaction test. The compressive and tensile properties of tissues were evaluated using the elasticity test device. Results: Hematoxylin and eosin staining showed that the DP group and the T group were mainly composed of fibroblasts. The alignment of fibers was irregular. In the DPB group, the reconstructed tissues were composed of fibroblasts and chondrocytes, with parallel fibers and denser structure. The native labrum was composed of a large number of fibroblasts, which were arranged orderly and parallel, and there was almost no vascular proliferation. Under scanning electron microscopy, the reconstructed tissue of the DBP group was more similar to the native labral structure, forming a denser, clear-layered collagen fibrous structure, while the fiber alignment of the DP and T groups was irregular. The contents of type I, II, and III collagen (COL1, COL2, and COL3, respectively) were upregulated in labrum reconstructed with the DPB scaffold, while the gene expressions did not increase in the DP and T groups. The tensile and compressive properties of the implants in the DPB group were significantly enhanced. Conclusion: BMP-2 modified electrospun scaffold promotes collagen regeneration and osteogenic differentiation and is associated with better biomechanical performance of the reconstructed labrum. Clinical Relevance: This study demonstrated that BMP-2 modified electrospun scaffold could induce the regeneration of collagen and osteogenic differentiation and provide better biomechanical performance in labral reconstruction. This scaffold could be used in clinical practice after further improvement.