Hip Arthroscopy for Labral Repair in patients with Hip Dysplasia

SUMMARY STATEMENT: Hip dysplasia is a disorder of skeletal alignment that requires adjustment of the relationship between the femoral head and acetabulum – or hip socket – to correct the underlying pathology. In cases of hip dysplasia, the labral tears and chondral flaps – also called cartilage flaps – are the result of misalignment and are not the primary problem. Unless the misalignment is corrected, it is highly likely that soft-tissue repairs will break down again. The current procedure of choice for the treatment of hip dysplasia is skeletal re-alignment with procedures such as the Peri-acetabular osteotomy (PAO) instead of arthroscopy as an isolated procedure until there is further clarification of the long-term outcomes of isolated hip arthroscopic procedures for management of damage that is caused by the hip dysplasia.

RATIONALE: In general, hip arthroscopy is avoided as the main treatment for hip pain or hip deterioration from hip dysplasia. Hip arthroscopy without bony correction of dysplasia may not resolve symptoms and may potentially increase symptoms, worsen femoral head displacement, or lead to more rapid progression of osteoarthritis (1,2).

The diagnosis of hip dysplasia can be complex, and identifying those patients with mild forms of dysplasia is difficult.  Arthroscopy does not benefit obvious hip dysplasia with femoral head displacement, but there are cases of mild dysplasia and other causes of hip pain such as femoroacetabular impingement that might be appropriate for arthroscopic surgery when impingement, not dysplasia, is the predominate problem.

It is critical that a careful history, physical exam, and x-rays be performed by a surgeon with experience in recognizing hip dysplasia in order to determine the approaches that are reasonable on a case by case basis.  Also these subtle / borderline cases will require further study to determine the optimal surgical approaches and treatments because hip arthroscopy in mild cases of dysplasia is unpredictable.

There very little information in the scientific literature regarding benefits or risks of hip arthroscopy in the setting of hip dysplasia. However, hip dysplasia is mainly a problem of bone alignment that may cause damage such as labral tears or instability. Fixing the tears and damage without correcting the bone deformity does not address the underlying problem for most patients.  Only one study reported short-term improvement for patients with hip dysplasia who underwent arthroscopic repair of labral tears (3). However, this should be interpreted with caution because there is no long term information on this strategy.  Furthermore, during access to the hip with arthroscopic procedures, the ligaments about the hip capsule may be damaged, which may destabilize the dysplastic hip (2). In instances where patients with dysplasia choose to undergo arthroscopy instead of peri-acetabular osteotomy (PAO) for short term symptomatic relief, it may be worthwhile to discuss the potential risks stated above, and to continue regular follow-up for evaluation of continued symptoms, instability, or progression of arthrosis.

Arthroscopic surgery of the hip does have a role when combined with bone procedures that re-align the joint such as the PAO. This combined approach may be used to manage intra-articular pathology and mechanical symptoms caused by labral tears or cartilage flaps.  It has been shown that labral tears occur in 65%-77% of patients who have hip dysplasia (4,5).  There are not enough long-term outcomes to clarify whether labral repair or débridement combined with PAO will improve the overall outcomes as compared to PAO alone. Nonetheless, when the labrum is torn, it is the preference of some surgeons to carry out arthroscopic labral repair at the same time as a PAO. This is a reasonable option based on the biomechanical function of the labrum, but mainly when combined with a PAO.

To summarize: Unless the malalignment is corrected, it is highly likely that soft-tissue repairs including labral repair will break down again. Until there is clarification of the long-term outcomes of hip arthroscopy alone for management of symptoms caused by hip dysplasia, the current procedure of choice for the treatment of hip dysplasia is generally skeletal re-alignment surgery.


References:

  1. Parvizi J, Bican O, Bender B, Maotazavi SM, Purtill JJ, Erickson J, Peters C. Arthroscopy for labral tears in patients with developemental dysplasia of the hip, a cautionary note. J Arthroplasty 2009 Sept:24(6 suppl):110-3
  2. Mei-Dan O, MCConkey MO, Brick M. Catastrophic failure of hip arthroscopy due to iatrogenic instability, can partial division of the ligamentum teres and the iliofemoral ligament cause subluxation? Arthroscopy 2012 Mar; 28(3):440-5
  3. Byrd JW, Jones KS. Hip arthroscopy in the presence of dysplasia. Arthroscopy. 2003 Dec;19(10):1055-60.
  4. Fujii M, Nakashima Y, Jingushi S. et al. Intraarticular findings in symptomatic developmental dysplasia of the hip. J Pediatr Orthop. 2009 Jan-Feb;29(1):9-13.
  5. Ross JR, Zaltz I, Nepple JJ, et al. Arthroscopic disease classification and interventions as an adjunct in the treatment of acetabular dysplasia. Am J Sports Med 2011;39 Suppl 1:72S-78S.
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