Doctors question Hip Labrum Surgery – Others support injection therapies
The hip labrum is an important ring of cartilage that holds the femoral head, or top of the thigh bone, securely within the hip anatomy. It also serves as a cushion and shock absorber to protect the hip and thigh bones. Damage or degeneration to the labrum causes pain and joint instability and overgrow bone in attempt to stabilize the area.
Hip labrum injury and labral tears
Hip labrum injury and labral tears can be caused by a sudden, specific injury or with repetitive motions that cause “wear and tear.” Patients come into our office with varying degrees of hip pain and may also
describe a pain deep in the groin.
The patient may also describe a clicking, popping or a locking sensation in the hip. While they may describe more symptoms, one thing they all seek is hip labrum pain relief and a return of hip function and stability.
Simply a patient seeking hip labrum injury treatment can research two options. A non-surgical option and a surgical option. Almost all patients start with the “conservative” non-surgical path, most of them end up on the surgical table.
Why does conservative treatments lead to surgical options? The easy answer is the conservative treatments were not effective for the patient. But conservative treatments are a broad term to describe many options. Perhaps the patient and his/her health care provider did not seek a broader selection of options and did not select the correct conservative treatment. We will cover these options below.
Labral hip tears are grouped into four classifications
- anterior superior labrum hip tear (front of hip)
- posterior superior labrum hip tear (front and top of hip)
- superior labrum hip tear (towards the rear of the hip)
- posterior labrum hip tear (the rear of the hip)
Hip labral tear treatment – traditional conservative options lead to surgery
The labrum has a poor blood supply, which makes a tear or injury difficult to treat with conservative approaches such as<ahref=”http://www.caringmedical.com/sports-injuries/rice-why-we-do-not-recommend-it/”>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 shown limited clinical benefit.1 The problems of cortisone injections are discussed at length in our article alternatives to cortisone by Ross Hauser MD. Also see his articles on viscosupplementation which may be used in conjunction with oral NSAIDs and physical therapy and NSAIDs and their capacity to cause more pain.
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 patient/athlete would be able to return fully to his or her work or sport, especially if labral tissue is removed.
Hip labral tear surgery
One of the main questions we are often asked is what are hip labral tear surgery success rates? Let’s let the research answer and let’s take a very positive surgical study, in fact here is what the conclusion states: “Primary hip arthroscopy for all procedures . . . had excellent clinical outcomes and patient satisfaction scores at short-term follow-up in this study.”
Excellent clinical results included:
During this research study period between April 2008 and October 2011, data were collected on all patients who underwent primary hip arthroscopy. A total of 595 patients were included in the study.
- Forty-seven (7.7%) patients underwent revision hip arthroscopy, and
- 54 (9.1%) patients underwent either a total hip replacement or the hip resurfacing procedure during the study period. 2
- Nearly 17% of the patients who had hip arthroscopy went in for a second surgery within two years. Two surgeries – two years.
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).3 If the labrum is not there the hip bone “floats” and causes hip instability which can lead to a further degeneration of the hip which will lead to hip replacement.
Concerns about hip labrum MRI and surgical recommendation
This research from April 2016 should concern patients over the age of 50 who had a 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. . . 4
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) 5
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. Here is the research:
- 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.5
Surgeons discuss saving the hip labrum
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
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 with a 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.9
It all comes back to saving the hip labrum, as documented by the research
“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 to enhance labrum surgery recovery, “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.”10
Injection treatments for hip labrum tear
The excitement surrounding biomaterials, in this case Platelet Rich Plasma Therapy revolves around the role Platelets play 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.11-14
Prolotherapy for Hip Labrum Tears
In our practice, before we go directly to PRP or Stem Cell Therapy, we may first explore Prolotherapy.
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 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.[Pubmed]
2 Gupta A, Redmond JM, Stake CE, Dunne KF, Domb BG. Does Primary Hip Arthroscopy Result in Improved Clinical Outcomes?: 2-Year Clinical Follow-up on a Mixed Group of 738 Consecutive Primary Hip Arthroscopies Performed at a High-Volume Referral Center. Am J Sports Med. 2016 Jan;44(1):74-82. doi: 10.1177/0363546514562563.[Pubmed]
3 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.[Pubmed]
4. 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. [Pubmed]
5 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.[Pubmed]
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.[Pubmed]
7. Salata MJ, Vasileff WK. Management of Labral and Chondral Disease in Hip Preservation Surgery. Sports Med Arthrosc. 2015 Dec;23(4):200-4. [Pubmed]
8. Groh MM, Herrara J. A comprehensive review of hip labral tears. Curr Rev Musculoskelet Med. 2009 June; 2(2): 105–117. [Pubmed]
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.