A Vote Against the Widespread Adoption of Primary Labral Reconstruction

Commentary Labral management during hip arthroscopy is an evolving and controversial topic. Hip arthroscopic techniques have advanced in parallel with the increased utilization of the procedure since the early 2000s, at which time debridement was the primary method of labral management. The outcomes of modern labral repair and reconstruction techniques have been studied, but direct comparison between them is challenging because of inherent differences between hips with an irreparable labrum and those with a simple labral tear. Dornan et al. take a unique approach to this problem by utilizing a statistical model to control for these otherwise confounding differences between hips undergoing labral repair versus labral reconstruction. With the progressive achievement of the collective learning curve and the publication of the initial outcomes of labral reconstruction, some hip arthroscopists have advocated for expanding the indications for primary labral reconstruction. Most hip arthroscopists agree that primary labral repair is the appropriate choice in a young patient with a simple labral tear, and most would pursue primary labral reconstruction in a nonarthritic hip with severe labral degeneration, deficiency, or calcification. The gray zone houses the debate. Citing the noninferiority of labral reconstruction, even in view of the more severe pathology in hips classically indicated for this procedure compared with hips indicated for labral repair, some now advocate for primary labral reconstruction in hips with other influencing factors, such as moderate labral damage but an age older than 35 to 40 years, pronounced synovitis, or mild chondrosis1. Others have become even more aggressive in their treatment approach, adopting a near-complete shift to primary labral reconstruction and subsequently reporting outcomes that are superior to those seen with primary labral repair2. These claims have been met with resistance, creating a controversial environment around primary labral reconstruction. The present study by Dornan et al. contributes an additional voice to this debate. In the absence of a prospective randomized controlled trial (RCT) comparing primary labral repair and reconstruction, all existing studies on this topic have some imperfections. The reality is that hips indicated for these procedures vary vastly in their presentation, and even retrospectively matching for age, sex, cartilage status, osseous morphology, and labral tear size to eliminate these confounding variables is impractical. A previous study that included patients undergoing labral repair in 1 hip and labral reconstruction in the other sufficiently matched patient characteristics but did not control for hip joint pathology and has been critiqued for not accounting for the impact of the learning curve on the chronological selection of all reconstruction cases later in the surgeon’s practice2. An RCT to settle this debate, while ideal, would be a massive undertaking. The study by Dornan et al. is an excellent effort at creating a “next best” alternative to an RCT. Pairing an inverse propensity score model and a weighted multiple regression model, the authors adjusted for >20 covariates, including hip cartilage status, labral tear size, patient age, sex, and body mass index, among others, that could otherwise introduce confounding effects. This statistical approach allowed for a fairer comparison of a large sample of patients, who ranged from 18 to 80 years old, without a need to perfectly match for these variables. To my knowledge, there are no other studies with such a large and generalizable sample size as this one, which included 150 hips undergoing primary labral reconstruction and 998 hips undergoing primary labral repair. With a median follow-up of >5 years and a minimum follow-up of 2 years, this study was well suited to comment on patient-reported outcomes (PROs) that are known to maximally improve within 2 years, but it may have missed some longer-term outcomes such as conversion to arthroplasty, particularly in the younger patients. Nonetheless, the labral reconstruction group demonstrated worse PROs than labral repair and a strikingly higher rate of conversion to arthroplasty (20% versus 7%). The limitations of this study, including the lack of randomization in the surgical procedure selection, the performance of all procedures by a single surgeon, and imperfect follow-up rates, are sufficiently discussed by the authors. The strength of this study is precisely the efforts to control for these flaws with the use of inverse propensity score and weighted multiple regression models, along with multiple imputation for missing data. Overall, this study serves as a suitable backup to an RCT by analyzing the outcomes following primary labral repair and labral reconstruction while controlling for multiple confounding variables across a large, generalizable sample. On the basis of their study findings, Dornan et al. provide a sage word of caution against the widespread adoption of labral reconstruction for otherwise reparable labra. This study is a vote in favor of labral repair remaining the gold standard in primary hip arthroscopy whenever feasible, with reconstruction remaining a salvage procedure.