5 of 12 Top Hip Papers of 2024 | Long term impacts of arthroscopic labral and capsular management
It's day 5 of my 12 Top Hip Papers series of miniblogs from 2024! If you missed any of the previous days, you'll find a link at the bottom of this page to work backwards, or you can visit the main page here - 12 top papers of 2024. For day 5 we'll be taking a look at the impacts of labral and capsular management 10+ years after hip arthroscopy.
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5 of 12 Top Hip Papers of 2024: Impacts of labral and capsular management 10+ years after hip arthroscopy1
This study reported on the long-term outcomes of primary hip arthroscopy for labral tears in painful hips, with a particular focus on the effects of labral and capsular management.
Background:
- While the most common surgical management of labral tears has traditionally been labral debridement (trimming), contemporary management has shifted from debridement to repair or sometimes reconstruction, to improve outcomes and lower reoperation rates.
- Capsular repair after arthroscopy has also become much more common, due to short and medium term evidence of improved outcomes.
- Limited evidence on longer term outcomes of hip arthroscopy is available, and studies that are available are usually of small size with heterogenous populations and procedures.
Study Aim:
This study aimed to:
- Evaluate outcomes of primary hip arthroscopy at a minimum 10-year follow-up at two academic centers by describing patient-reported outcomes and determining re-operation and total hip arthroplasty (THA) rates.
What was done:
A case series of 294 patients undergoing primary hip arthroscopy (age 40 ± 14 years; 66% women; BMI 27 ± 6) with follow up over for 12 ± 3 years (range, 10-24 years).
Surgical Techniques:
- Labral debridement 41.2%
- Labral repair 58.8%
- Isolated interportal capsulotomy 98.3%
- T-capsulotomy 1.7%
- Capsular repair 10.5%
- Cam resection 66.7%
Outcomes Measured:
- Tegner Activity Score
- VAS -pain at rest & with use
- iHOT-12
- modifed Harris Hip Score
- Hip Outcome Score - ADL
- Hip Outcome Score - SS
- Non-Arthritic Hip Score
- Surgery satisfaction
- Current level of function
Labral debridement or repair and cam resection were the main surgical techniques with variable capsular management. Of interest was a note from the authors regarding a gradual change in their clinical practice over the study time period. Surgeons started shifting from labral debridement (trimming off the labrum) toward labral repair, and they were also more likely to repair the hip capsule, due to perceived improvements in patient outcomes.
Key Findings:
- Patient factors predisposing to conversion to total hip arthroplasty included older age, higher Tonnis grade (worse joint status), and potentially modifiable surgical factors - labral debridement and capsular non-repair.
- Labral repair was associated with lower rates of progression to total hip arthroplasty compared with labral debridement. The labral debridement group had a higher Tonnis grade (poorer joint status) the time of primary arthroscopy, but even after adjustment, labral repair was still a significant predictor of lower conversion to total hip arthroplasty (hip replacement).
- Capsular repair was associated with lower rates of progression to total hip arthroplasty compared with no capsular repair. There was no significant difference in Tonnis grade (joint status) between groups at the time of primary arthroscopy.
- The overall highest rate of conversion to total hip arthroplasty was in patients who underwent labral debridement with no capsular repair.
- Patients who underwent labral repair with capsular repair had an almost 10-fold decrease in conversion to total hip arthroplasty.
Clinical Implications:
- Labral debridement and lack of capsular repair may give rise to microinstability and increased translatory forces, potentially prediposing to greater rates of joint wear over time.
- This study provides long-term evidence that labral and capsular repair during arthroscopy may be protective for the joint, reducing rates of conversion to hip replacement.
This study found that labral debridement and a lack of capsular repair were both associated with higher rates of progression to total hip replacement, compared with labral and capsular repair.
These long term outcomes suggest that labral debridement and a lack of capsular repair during arthroscopy may increase risks of micro-instability and higher rates of degenerative joint change. While age, body mass index and joint status at the time of primary hip arthroscopy are major factors that impact on rates of conversion to total hip arthroplasty, there are surgical factors that are modifiable and potentially protective, such as labral and capsular repair.
Many patients undergoing arthroscopy for joint pain associated with labral tear assume that their labrum will be 'fixed' by the surgery. Debridement - trimming of the labrum - remains the most common procedure for addressing labral tears, and this does not restore labral function. In fact, research has indicated that debridement of the labrum may leave the hip more at risk than the tear itself. Pain will usually be reduced, as nociceptive nerve endings within the damaged labrum are removed, but this does not 'fix' the labrum unfortunately.
Labral repair is more technically challenging, particularly where tissue quality is poor, but this study shows that where possible, it might be the best option in the longer term. This study also adds to the growing body of evidence around the benefits of repairing the hip joint capsule after hip arthroscopy. Many surgeons still do not repair the capsule, but the tide is hopefully changing.
Rehabilitative health professionals should be aware of the surgical procedures that have occurred in patients for which they are providing post-operative services, and the implications for early rehabilitation precautions and longer term risks and outcomes.
Like to learn more about the importance of the labrum and capsule to joint health?
In this course, you can find detailed information on pathoaetiology, assessment and management of joint related hip pain and many other causes of anterior hip and groin pain. To learn more, take the anterior hip and groin pain online course, or join me in an online or practical anterior hip and groin pain workshop.
This online course is included in Hip Academy and Hip Academy members receive discounts for online workshops. In Hip Academy, you will also find an additional meeting masterclass recording on post-operative management after hip arthroscopy.
I hope you enjoyed the infographics and key learnings from Day 5 of my 12 Top Hip Papers of 2024. There are 7 more papers to come, so keep and eye out, to see what other top papers and infographics I have for you!
Missed paper 4? Click above to read it!
Paper 6 comes out tomorrow!
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