Torn Hip Labrum Repair
Ross Hauser, MD
- Surgery: 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.1
- Surgery: Resection (removal) of a nonreparable 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.2
- Cortisione: In patients with pain from femoral acetabular impingement (FAI) and labral tear, intra-articular cortisone injection has limited clinical benefit.3
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.
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.
The labrum is a smooth ring of fibrocartilage that surrounds the ball and socket joint of the hip. As one of the main stabilizing structures of the hip, the labrum increases the surface area and strength of the hip joint and prevents the femur from slipping out of place. Damage to the labrum causes pain and joint instability, which subjects other structures of the joint to further injury. One of the body’s responses to joint instability is to overgrow bone in attempt to stabilize the area. In femoral acetabular impingement, it is believed that pain is due to bones of the hip joint coming too close together during movement and pinching various tissues such as the labrum and cartilage. It is not known what causes femoral acetabular impingement, but in the case of our patient, it is possible that joint instability, caused by his damaged labrum, was the stimulus for the overgrowth of bone and thus the impingement. However, it is also possible that the pain the patient experiences is not in fact due to impingement, but instead may be originating from the torn labrum or injured ligaments and tendons surrounding the joint.
Problems with surgery for hip labrum tear
The study mentioned above points out the problem with completely removing the labrum but also points 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 osteoarthritiis.”4
Platelet Rich Plasma Therapy treatment for hip labrum tear
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.
In basic terms, PRP involves the application of concentrated platelets, which release a supra-maximal quantity of growth factors which stimulate recovery in non-healing injuries. PRP causes a mass influx of growth factors, such as platelet-derived growth factor, transforming growth factor and others, which exert their effects of fibroblasts causing proliferation and thereby accelerating the regeneration of injured tissues. Specifically PRP enhances the fibroblastic events involved in tissue healing including chemotaxis, proliferation of cells, proteosynthesis, reparat5on, extracellular matrix deposition, and the remodeling of tissues. Bottom line here is that tissues can heal faster with PRP! 5-9
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. We do not feel surgical labrum removal is the best option for first line treatment, nor do we agree with surgeons inserting titanium stables in the hip for so-called “repair.”
References for this article
1. 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.
2. 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. 2014 Nov 4. [Epub ahead of print]
3. 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.
4. Groh MM, Herrara J. A comprehensive review of hip labral tears. Curr Rev Musculoskelet Med. 2009 June; 2(2): 105–117.
5. Pietrzak WS, Eppley BL. Platelet rich plasma: biology and new technology. Journal of Craniofacial Surgery. 2005; 16:1043-1054
6. Crane D, Everts P. Platelet Rich Plasma Matrix Grafts. Practical Pain Management. 2008; Jan/Feb: 12-26.
7. 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.
8. 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:
9. 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.