Patient Satisfaction after Arthroscopic Repair of Acetabular Labral Tears

Between September 2007 and August 2010, we performed arthroscopic surgery in 207 patients. Of them, 21 patients that underwent arthroscopic labral repair were included in this study. They were followed-up for a minimum of 2 years postoperatively. The indications for surgery were hip pain with associated mechanical symptoms and intractable pain after conservative treatment for at least 12 weeks. On physical examination, all had a painful range of motion with positive impingement test (flexion, adduction, and internal rotation). Preoperative imaging included plain radiographs (pelvis anteroposterior and frog leg) and computed tomography (CT) arthrogram to detect bony impingement and labral tear. We excluded those who had undergone previous hip surgery and those with avascular necrosis, rheumatologic disorder and patients with arthritis on radiography (Tonnis grade > 2).

There were 10 men and 11 women with a mean age of 35 years (range, 22 to 57 years). The minimum follow-up was 2 years. Preoperative diagnoses included isolated labral tear in 11 hips, cam-type impingement in six hips, and pincer-type impingement in four hips. Preoperative radiographs revealed Tonnis grade 0 to 1 changes in 20 hips and grade 2 changes in one hip (Table 1).

Table 1
Patient Demographic Data

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We performed hip arthroscopy using a standard fracture table with patient in the supine position. Traction was applied with slight extension and adduction of the hip joint with enough force to open the joint approximately 1 cm. Two or three portals (anterolateral, anterior, and/or posterolateral) were placed for arthroscopic labral repair. A suture anchor was placed on the capsular side ad secured, followed by a suture passer was used to deliver a limb suture through a small portion of the substance of the labrum. An arthroscopic sliding knot was tied and passed down the cannular to secure the repair. The operation was completed by joint lavage and injection with local anesthetic. All operations were performed by one surgeon (Fig. 1).

Fig. 1
A case of a 24-year-old man with hip pain mechanical symptoms. (A) Computed tomography arthrography shows an anterosuperior labral tear (1 o'clock to 2 o'clock position). (B) Arthroscopic finding shows a peripheral longitudinal labral tear. (C) Arthroscopic view shows labral repair with two suture anchors.

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Postoperatively, all patients followed a standardized rehabilitation program. Immediately after surgery, passive and active range of movement was permitted. Patients were kept toe-touch weight bearing for 2 weeks with range of motion encouraged but avoiding extremes of external rotation. In general, patients typically required 2 to 3 weeks of crutch assistance. Patients who underwent microfracture were kept toe-touch weight bearing for 6 to 8 weeks. Clinical and radiographic follow-up evaluations were performed at the 6 weeks, 3 months, 6 months, 12 months, and every 6 months thereafter. Patients that did not attend regularly scheduled visits were contacted by telephone.

Patient satisfaction was evaluated by interview at the last follow-up. Clinical evaluations were performed using Harris hip score (HHS),10) visual analog scale (VAS), Western Ontario and McMaster Universities (WOMAC) osteoarthritis index, University of California, Los Angeles (UCLA) activity, and a satisfaction survey. Radiographic analyses included anteroposterior view of pelvis, frog-leg lateral view, and translateral view of hip. All radiographs were assessed using the Tonnis classification,11) which was used to grade radiographic degenerative changes, and the Outerbridge classification system,12) which grades the degree of chondromalacia.

The difference between preoperative and postoperative outcome measures were analyzed using Wilcoxon signed rank test for continuous outcome measures and Fisher exact test for categorical outcome measures. We rejected null hypotheses of no difference if p-values were < 0.05. For statistical analyses we used SPSS ver. 15.0 (SPSS Inc., Chicago, IL, USA).

The study was approved by our Institutional Review Board for biomedical research.

Improved instrumentation and arthroscopic surgical technique have extended indications for hip arthroscopy. Although most studies reported encouraging short to midterm results of arthroscopic treatment of labral tear, all of these studies were conducted in western countries (Table 3). To our knowledge, this is the first study regarding acetabular labral repair in an Asian country. Eighteen of 21 patients were satisfied with relief of pain and/or improvement of their functional outcome with no progression of arthritic change of radiographic evaluation at the minimal 2 year follow-up.

Table 3
Summary of Outcomes of Arthroscopic Labral Repairs

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Bedi et al.7) performed a systemic review to assess outcomes after surgical treatment of labral tears and femoroacetabular impingement (FAI). They reported 65% to 85% of patients who underwent open surgical procedures were satisfied with the outcome at a mean of 40 months after surgery as compared to 67% to 100% of patients who underwent arthroscopic surgery who were satisfied. They concluded that there was no difference between open surgery and arthroscopic procedure. Therefore, arthroscopic surgery in hip pathologic conditions could substituted for open surgery. However, most of the published research has addressed debridement of torn acetabular labrum. With increasing knowledge about the function and importance of the labrum, surgical techniques including suture anchor repair must be encouraged to maintain the function of the hip joint and decrease the development of early arthritic change. Larson et al.6) compared the outcomes of arthroscopic labral debridement (44 patients) versus refixation (50 patients) in 94 patients at a mean follow-up of 3.5 years. They concluded that labral refixation resulted in better outcomes and a greater percentage of good to excellent results compared with the results of labral debridement. Schilders et al.8) compared arthroscopic labral repair (69 hips) and resection (32 hips) in 96 patients (101 hips) at a mean follow-up of 2.4 years. They also concluded that labral repair provides a superior result to labral resection. Although we could not compare debridement with repair in our series, our findings are consistent with previous studies. In this study, the HHS improved from 73 points (range, 64 to 84 points) preoperatively to 83 points (range, 66 to 95 points) postoperatively, and the UCLA activity improved in 16 patients and remained similar in two patients at the latest follow-up. Eighty-six percent (18/21) of patients were satisfied with their arthroscopic labral repair.

Beaule et al.5) reviewed acetabular labral tear and mentioned that acetabular labral tears rarely occur in the absence of a structural osseous abnormality, such as FAI. FAI is a proposed etiology of early osteoarthritis in young patients.13, 14, 15) However, the incidence of hip osteoarthritis in the general population has marked ethnic and racial differences.16) The rate of moderate to severe idiopathic and secondary hip osteoarthritis in Caucasians is 3%-6% compared with ≤ 1% in East Indians, Blacks, Hong Kong Chinese, and Native Americans.17, 18, 19) Epidemiologic data suggest that the incidence of FAI and acetabular labral tear in Asian countries might be lower than in Western countries.16, 17, 18, 19) However, if the patients have acetabular labral tear with osseous abnormality, daily activities are more seriously inconvenienced in Asian patients, as the Asian life style and culture requires more flexion and abduction motion of the hip joints. Seventy one percent (15/21 patients) in this study reported excellent and good results at the minimum 2-year follow-up. This finding is comparable with studies in Western countries. Ilizaliturri et al.20) performed arthroscopic surgery on 19 hips who were diagnosed with FAI with labral tear and reported 84% good to excellent results at the minimum follow-up of 24 months. Larson and Giveans21) compared the outcomes of arthroscopic labral debridement (36 hips) with those of labral refixation (39 hips). They reported 89.7% good and excellent results in refixation groups at the minimum follow-up of 12 months.

This study has several limitations. Firstly, there was no control group and the total numbers of patients were small. Nevertheless, this study proves the value for athroscopic procedures on acetabular labral tear with or without osseous abnormality. Secondly, acetabular labral tear is frequently associated with other osseous structural abnormalities, such as cam and/or pincer-type deformities. Therefore, it is difficult to evaluate isolated the effects of arthroscopic labral repair. It is an inevitable limitation of this study. Finally, preoperative patient expectations were not evaluated. However, we evaluated and did confirm the 86% satisfaction rate at minimum 2-year follow-up.

In conclusions, arthroscopic labral repair resulted in 86% satisfaction and 71% good to excellent results at a 2-year follow-up. Therefore, the hip arthroscopic procedure might be an excellent alternative to open surgery and promises greater probability of good to excellent results.