Research: If It’s A Tear, Repair.
Updated: Feb 9, 2020
I’ve been around the block like a used car with my hips. They are not under warranty and should have been recalled years ago. They were part of the Hip Arthroscopy 1.0 Edition. This edition was 11 years ago where the standard protocol for even my then top-notch surgeon was to debride the labrum and leave the capsule open (ie…make a cut through the ligaments and not sew them back up).
Fortunately, this field has completely remodeled itself. There are many debates in the field of hip arthroscopy and one of those debates is whether to debride (trim) a torn labrum or to repair it with suture anchors. So, let’s chat about some of the recent press on this topic.
A recent article entitled, “Surgical Treatment of Labral Tears: Debridement, Repair, Reconstruction” by Woyski and Mather discusses this very matter. In fact, the authors provide a “decision bubble” for decision making as to the use of debridement, repair and reconstruction.
Under the repair category facts that should be considered include the age and activity level of the patient, whether this is a first hip surgery (or not) and if there is instability in the “labral base”. Two other factors that should be considered in the repair category, per Woyski and Mather, are the quality of the labral tissue and whether it would appear that the “suction seal” can be restored.
The next category that the authors look at to consider for debridement is the level of activity of the patient (ie. less active may be more suitable for debridement), whether there is “adequate bony stability” and minimal arthritis. The reconstruction decision making process includes whether the hip scope is a revision, the “increasing” age of the patient and whether there is a “loss of the chondrolabral junction” and whether the labrum is “ossified”.
Woyski and Mather also go on to state, “In the treatment paradigm of labral tears, arthroscopic labral repair has emerged as the leading treatment option for most tears regardless of etiology.” When I hear that as a patient, I focus in on that word, “most”. To me, the word implies that there are other times that the other options may be appropriate. The best thing that you can do is find a doctor who is well versed in and very well qualified for all three options. Steer away from a surgeon who only does the same procedure for all of his patients as that could be an indication that the management of your hip is not being individualized. For example, if he or she only debrides, then maybe rethink and get a second or third opinion.
Another article by Chambers and Zhang entitled, “Outcomes for Surgical Treatment of Femoroacetabular Impingement in Adults” indicates how important the suction seal is. What the authors are referring to is the labral tissue and its effect on the stability of the joint as well as the ability for it to maintain the proper joint fluid levels. Chambers and Zhang indicate that the labrum is “chondroprotective” meaning it protects the health of the cartilage. The authors also refer to a paper done by Wolff and Grossman when they state, “Labral repair and reconstruction have been shown to restore intra-articular fluid pressurization and suction seal restoration to the native state, while debridement does not, leading to the general belief that labral preservation with repair rather than excision or debridement is preferable.”
Things to consider when speaking with your doctor include:
Is he or she highly qualified in performing all three of the procedures (debride, repair, reconstruction)? How many does he or she do a year? Is he or she fellowship trained in hip preservation?
What percentage of each procedure does he or she use? If 100% of his or her scopes are debridement only, then that should be a red flag for you to dig deeper as to rationale.
What are his or her thought processes when making that decision? Is he or she looking at your hip’s ability to maintain the suction seal? Does he or she believe that debriding only can keep the suction seal intact?
What types of scenarios would he or she see that could cause a different decision during surgery?
A doctor’s goal is to use the least amount of interventions that can achieve the best chance of success, but you need a doctor who can go in and make that decision based on your unique case and not just because he or she does it a specific way for all of his or her patients. Going back to my used car analogy, you would not want a car repairmen giving all car owners the same part for different problems. The same applies for your hips – the surgical plan should be specific to your hips.
Chambers, C.C., Zhang, A.L. Outcomes for Surgical Treatment of Femoroacetabular Impingement in Adults. Curr Rev Musculoskelet Med 12, 271–280 (2019). https://doi.org/10.1007/s12178-019-09567-1
Wolff AB, Grossman J. Management of the acetabular labrum. Clin Sports Med. 2016;35(3):345–360. doi: 10.1016/j.csm.2016.02.004.
Woyski, D., & Mather, R. C., 3rd (2019). Surgical Treatment of Labral Tears: Debridement, Repair, Reconstruction. Current reviews in musculoskeletal medicine, 12(3), 291–299. doi:10.1007/s12178-019-09575-1