Before you have a surgery for a Torn Hip Labrum
In this article Danielle R. Steilen-Matias, MMS, PA-C discusses various methods of acetabulum hip labrum repair including regenerative and biomaterials such as Platelet Rich Plasma Therapy and stem cell therapy.
The Hip labrum is cartilage that acts as a shock absorber that cushions the hip socket. In this article Labrum is the noun for the actual cartilage – labral acts as an adjective to describe the tears.
Labral tears can be caused by a sudden, specific injury or with repetitive motions that cause “wear and tear.” Patients have pain deep in the groin on the side of the involved hip. This may be accompanied by a clicking, popping or a locking sensation in the hip, all the while the patient exhibits varying degrees of hip pain.
Hip labral tear treatment options
This research from May 2016 should concern patients thinking of a surgery for removal of their hip labrum.
“(the) hip joint does not act as a true ball-and-socket joint and the femoral head anatomical displacement is strongly affected by the removal of periarticular soft tissues, labral repair as well as labrectomy (removal of the labrum).1
This research from April 2016 should concern patients over the age of 50 who had an MRI for suspected hip labral tears and were recommended to surgery.
Arthroscopy for acetabular labral tears has minimal impact on pain and function in older patients, especially in the setting of concomitant osteoarthritis. Still, many physicians seek this diagnosis with MR arthrography. . . 2
This is may be why patients often question hip labral tear surgery success rates.
In a recent study doctors expressed concern that there does not appear to be options for patients showing degenerative labrum hip tear symptoms: painful, torn, irreparable, or completely ossified (calcified) acetabular labrum short of reconstruction with grafts.
It had been suggested that regeneration of the acetabular labrum was possible after excision or removal of the diseased labral tissue but studies are inconclusive and one study says it does not happen. (cited also below)3 It may not happen because diseased tissue is a building block of repair. This may also be why labrum surgery recovery can be difficult in many patient and the prognosis is often challenging.
In other research doctors suggested that radial and circumferential labral tears significantly decrease hip stability and significantly alter strain patterns in the anterior and anterior–superior acetabular labrum.4
The hip labrum is a cartilage ring that holds the thigh bone to the hip socket at the acetabulum. The place where the head of the thigh bone (or femur) meets the pelvis at the hip socket.
Damage or degeneration to the labrum causes pain and joint instability and overgrow bone in attempt to stabilize the area. In femoral acetabular impingement, it is believed that pain is due to the bones of the hip joint coming too close together during movement and pinching various tissues such as the labrum and cartilage.
The labrum has a poor blood supply, which makes a tear or injury difficult to treat with conservative approaches, such as pain medicine or rest. These particular recommendations have very little long term appeal, especially for an active person who does not want to take medication long term. Physical therapy may also be recommended for rehabilitation. In patients with pain from femoral acetabular impingement (FAI) and labral tear, intra-articular cortisone injection has limited clinical benefit.5
Labral hip tears are grouped into four classifications
- anterior superior labrum hip tear
- posterior superior labrum hip tear
- superior labrum hip tear
- posterior labrum hip tear
While physical therapy can help the surrounding muscles, it does not promote repair to the the labrum or prevent further instability of the hip joint. Consequently, labral tear cases are quickly referred to surgeons for potential surgery to try and repair or remove the damaged tissue. The surgical prognosis is often guarded as to whether the athlete would be able to return fully to his or her sport, especially if labral tissue is removed.
- New research says that patients, forty-five years of age or older, who had arthroscopic labral surgery had a relatively high re-operation rate and minimal overall improvement with small clinical benefit.6
- Resection (removal) of a non-repairable acetabular labrum does not stimulate regrowth of tissue…patients who underwent this procedure had neither results in regrowth nor the restoration of consistently high hip function.3
In new research doctors summarized below – doctors acknowledge that the techniques utilized for the management of articular cartilage and labrum injuries during hip preservation surgery have changed dramatically because they had to figure out a way to preserve the hip labrum.7 Why?
An article published in Current Reviews in Musculoskeletal Medicine conducted a comprehensive review of hip labral tears that pointed out that hip surgeries that remove or debride the hip labrum are taking away from the vital function of the labrum and indeed motion of the hip.8
Conservative treatment may involve image-guided injection of cortisone or viscosupplementation in conjunction with oral NSAIDs and physical therapy. The problems of cortisone injections are discussed at length in my article alternatives to cortisone.
Damage to the labrum runs a broad spectrum, and the treatments are individualized, but span from debridement to repair and reconstruction. The overarching goal of labral treatment is to restore the native functions of the labrum to allow for more normal biomechanical function.
Similarly, cartilage injuries can be managed a number of different ways, including with debridement, microfracture or drilling, cartilage transplants, and higher level restorative techniques. These cartilage restoration techniques have evolved rapidly as well, and may include the use of scaffolds, allograft cartilage cells, and other stem-cell-related procedures.7
Problems with surgery for hip labrum tear
The studies mentioned above point out the problem with completely removing the labrum but also point to problems with tears: Doctors recognize that without the labrum, the articular cartilage must withstand significantly increased pressure, and a compromise of this system could lead to early joint deterioration. Research noted that a tear in the labrum would also likely destabilize the hip joint. This explains why there is an association between acetabular labral tears and early onset osteoarthritis.”
“Without the labrum, the articular cartilage must withstand significantly increased pressure, and a compromise of this system could lead to early joint deterioration. A study testing a labrum-free model of the hip showed that, without the labrum, contact stress may increase by as much as 92%. A tear in the labrum would also likely destabilize the hip joint. This explains why there is an association between acetabular labral tears and early onset osteoarthritis.”8
This is why research is now pointing surgeons towards the incorporation of biomaterials – blood platelets and stem cells into surgical procedures. “the need for biological solutions for the pre-arthritic and early arthritic hip continues to be a challenge for the sports medicine surgeon and hip arthroscopist. . . The future of hip arthroscopy and the use of biological agents for arthroscopic hip surgery are exciting.”9
Platelet Rich Plasma Therapy treatment for hip labrum tear
Hip labral tear injection treatments
Platelets play a central role in blood clotting and wound healing. Tissue repair begins with clot formation and platelet degranulation, which release the growth factors necessary for wound repair. Platelet-derived growth factors are biologically active substances that enhance tissue repair mechanisms.
After platelets are activated at a wound site, proteins are released that directly and indirectly influence virtually all aspects of the wound healing cascade. Studies have shown a direct correlation between the platelet concentration and the level of secretory proteins, as well as the amount of proliferation involved in the wound healing.10-14
In our own research, Prolotherapy for hip labral tears was curative in 54% of the patients (no pain at all after Prolotherapy) and overall relieved 80-85% of their pain, which in our experience will end up much better than surgical procedures, because the hip is now stable.
In the The Open Rehabilitation Journal research describes the effectiveness of Prolotherapy for hip labral tear and groin pain that concluded Prolotherapy for acetabular labral tear appears to be a safe and potentially effective treatment.
In this research, Prolotherapy was found to provide connective tissue growth responses and provide clinical benefit with low risks in musculoskeletal conditions. Further, Prolotherapy can be a cost-effective alternative to surgery for patients with hip pain and labral tear.15
We examined Sixty-one patients, representing 94 hips, who had been in pain an average of 63 months We treated these patients quarterly with dextrose Prolotherapy.
This included a subset of 20 patients who were told by their medical doctor(s) that there were no other treatment options for their pain and a subset of eight patients who were told by their doctor(s) that surgery was their only option.
Patients were contacted an average of 19 months following their last Prolotherapy session and asked questions regarding their levels of pain, physical and psychological symptoms and activities of daily living, before and after their last Prolotherapy treatment.
- In these 94 hips, pain levels decreased from 7.0 to 2.4 after Prolotherapy;
- 89% experienced more than 50% of pain relief with Prolotherapy;
- more than 84% showed improvements in walking and exercise ability, anxiety, depression and overall disability;
- 54% were able to completely stop taking pain medications.
We concluded: “Prolotherapy used on patients who presented with over five years of unresolved hip pain were shown in this retrospective pilot study to improve their quality of life even 19 months subsequent from their last Prolotherapy session.
The 61 patients with 94 hips treated reported significantly less pain, stiffness, crunching sensation, disability, depressed and anxious thoughts, medication and other pain therapy usage, as well as improved walking ability, range of motion, sleep, exercise ability, and activities of daily living. This included patients who were told there were no other treatment options for their pain or that surgery was their only option. The results confirm that Prolotherapy is a treatment that should be highly considered for people suffering with chronic hip pain.”15
References for this article
1 Zaffagnini S, Signorelli C, Bonanzinga T, Lopomo N, Raggi F, Di Sarsina TR, Grassi A, Marcheggiani Muccioli GM, Marcacci M. Soft tissues contribution to hip joint kinematics and biomechanics. Hip Int. 2016 May 14;26 Suppl 1:23-7. doi: 10.5301/hipint.5000407. Epub 2016 May 12.
2. Jayakar R, Merz A, Plotkin B, Wang D, Seeger L, Hame SL. Magnetic resonance arthrography and the prevalence of acetabular labral tears in patients 50 years of age and older. Skeletal Radiol. 2016 Apr 20. [Epub ahead of print]
3 Miozzari HH, Celia M, Clark JM, Werlen S, Naal FD, Nötzli HP. No Regeneration of the Human Acetabular Labrum After Excision to Bone. Clin Orthop Relat Res. 2015 Apr;473(4):1349-57. doi: 10.1007/s11999-014-4021-z.
4. Smith MV, Panchal HB, Ruberte Thiele RA, Sekiya JK. Effect of acetabular labrum tears on hip stability and labral strain in a joint compression model. Am J Sports Med. 2011 Jul;39 Suppl:103S-10S. doi: 10.11
5 Krych AJ, Griffith TB, Hudgens JL, et al. Limited therapeutic benefits of intra-articular cortisone injection for patients with femoro-acetabular impingement and labral tear. Knee Surg Sports Traumatol Arthrosc. 2014 Apr;22(4):750-5. doi: 10.1007/s00167-014-2862-3. Epub 2014 Feb 1.
6 Wilkin G, March G, Beaulé PE. Arthroscopic Acetabular Labral Debridement in Patients Forty-five Years of Age or Older Has Minimal Benefit for Pain and Function. J Bone Joint Surg Am. 2014 Jan 15;96(2):113-8. doi: 10.2106/JBJS.L.01710.
7. Salata MJ, Vasileff WK. Management of Labral and Chondral Disease in Hip Preservation Surgery. Sports Med Arthrosc. 2015 Dec;23(4):200-4. doi: 10.1097/JSA.0000000000000093.
8. Groh MM, Herrara J. A comprehensive review of hip labral tears. Curr Rev Musculoskelet Med. 2009 June; 2(2): 105–117.
9. Stubbs AJ, Howse EA, Mannava S. Tissue engineering and the future of hip cartilage, labrum and ligamentum teres. Journal of Hip Preservation Surgery. 2016;3(1):23-29. doi:10.1093/jhps/hnv051.
10. Pietrzak WS, Eppley BL. Platelet rich plasma: biology and new technology. Journal of Craniofacial Surgery. 2005; 16:1043-1054
11. Crane D, Everts P. Platelet Rich Plasma Matrix Grafts. Practical Pain Management. 2008; Jan/Feb: 12-26.
12. Sampson S, Gerhardt M, Mandelbaum B. Platelet rich plasma injection grafts for musculoskeletal injuries: a review. Current Reviews in Musculoskeletal Medicine. 2008; 3:165-174.
13. Rabago D, Best TM, Zgierska A, et al. A systematic review of four injection therapies for lateral epicondylosis: prolotherapy, polidocanol, whole blood and platelet rich plasma. British Journal of Sports Medicine. 2009; 43:
14. Sanchez A, Nurden AT, Zalduendo MM, et al. Platelet-released growth factors enhance the secretion of hyaluronic acid and induce hepatocyte growth factor production by synovial fibroblasts from arthritic patients. Rheumatology. 2007;46:1769-1772.
15. Hauser R, Hauser M, A Retrospective Study on Hackett-Hemwall Dextrose Prolotherapy for Chronic Hip Pain at an Outpatient Charity Clinic in Rural Illinois. Journal of Prolotherapy. 2009;2:76-88.
This article was updated 5/31/2016