Postoperative Care
Patients are placed in a postoperative hip brace and use a continuous passive motion machine 6 hours a day for 2 weeks, and an ice machine. They maintain 30 lb of foot-flat weight-bearing for 3 weeks, and begin a standard labral repair protocol on postoperative days 3 to 7.
Discussion
Hip labral preservation has evolved over the past 10 years, and current options for labral management include excision, débridement, labralization, repair, and reconstruction.1-13 Labral excision was studied by Miozzari and colleagues,8 who postulated on the basis of animal models that the labrum may regenerate. In their series of 9 patients treated with surgical hip dislocation and labral excision at average 4-year follow-up, repeat magnetic resonance angiography revealed no regeneration of tissue—modified Harris Hip Score was 83. The hip scores were less than those of patients treated with the same procedure with repair, and the authors concluded that defining labral débridement versus excision in the literature, and treating patients with primary repair or reconstruction techniques, may lead to better results. Their study used a small sample and was limited to an open procedure. Arthroscopic labral débridement in isolation was also a poor option for treatment of a labral tear. In a 2-year follow-up of 59 isolated labral débridement procedures, Krych and colleagues9 found 47% combined poor results.
There is level I evidence of the importance of labral repair. In 2013, Krych and colleagues7 conducted a randomized control trial of 38 female patients who underwent hip arthroscopy for FAI. At time of surgery, patients were randomly assigned to either débridement or repair. At 1-year follow-up, activities of daily living and Sports specific Hip Outcome Scores were statistically significantly superior in the repair group. On a subjective scale, 94% vs 78% of patients reported normal or near normal hips in the repair versus débridement groups respectively. Ayeni and colleagues20 performed a systematic review of 6 studies in an attempt to develop labral management recommendations. Five of the studies (N = 490 patients total) had improved results with labral repair over reconstruction. Although the studies had a low level of evidence, they found a trend toward improved results with labral repair. These studies highlight the importance of labral preservation and proper FAI management.
Techniques for labrum repair have advanced as well—from a looped suture technique to a base stitch and knotless independent tensioning.11-13 Restoration of the hip labrum function as a suction seal, fluid circulator and anatomic capsular repair is paramount to excellent results and stresses the importance of performing an anatomic labral repair.1-6 Knotless anchor repair is not novel and has been previously described. Fry and Domb12 reported on a knotless labral repair technique that uses push-lock devices (Arthrex) that do not allow for independent tensioning. Inversion-eversion was introduced to the literature by Moreira and colleagues,13 who described an independent tensioning technique that uses speed-lock anchors (Smith & Nephew). Our technique differs in that it involves a DALA portal; labral reduction and tensioning with a probe assist to ensure the second pass of the base stitch is at the apex of the labrum; and use of No. 1 instead of No. 2 suture. Although seemingly subtle, these differences allow for proper anchor placement nearer the rim, additional support in achieving precise suture placement, and less disruption of small labra. These differences are particularly relevant for smaller labra.
Evaluating repair techniques on the basis of high-evidence literature is challenging. In a matched-cohort study of 220 patients, Jackson and colleagues21 compared 2 techniques: looped and base stitch. At 2-year follow-up, patients in both groups showed improvement, and there was no statistically significant difference in patient-reported outcome measures between the groups. Sawyer and colleagues22 studied the outcomes of 326 consecutive patients who underwent looped, pierced, or combined labral repair at an average 32-month follow-up. The groups’ revision rates were comparable, each group improved in postoperative patient-reported outcomes, and the pierced group had significantly higher preoperative scores on the Western Ontario and McMaster Universities Osteoarthritis Index. These studies described a base or pierce repair that did not differ from a looped repair, though the techniques did not allow for independent tensioning to re-create an anatomical inversion-eversion repair and may have altered the reported outcomes.
Our current technique uses independent tensioning of the repair to allow control of labrum inversion-eversion to give an anatomical repair with restoration of the suction seal. Preoperative planning, addressing the FAI appropriately, proper suture-passing technique, controlling the labrum in inversion-eversion fashion, and anatomical labral repair are the elements of Dr. Mather’s preferred method for preserving the native labrum and allowing it to assume its native function.