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, hip instability and bone overgrowth in attempt to stabilize the area.
- If you have questions about Hip Labrum Surgery, You can get help and information from our Caring Medical staff
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 with hip pain suspected to the hip labrum 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. The poor blood supply to the labral area also makes for recovery after hip labrum surgery at best challenging.
Conservative approaches include
- Rest and Ice, recommendations we usually will not suggest to a patient. Please see our article Rest ice compression elevation | Rice Therapy and Price Therapy for our reasoning.
- Pain medications. This particular recommendation has 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 hip labral tear, intra-articular cortisone injection has shown limited clinical benefit as pointed out in research from the Mayo Clinic.(1)
- The problems of cortisone injections are discussed at length in our article alternatives to cortisone by Ross Hauser MD. Also see my article Hyaluronic acid vs platelet-rich plasma in the treatment of hip osteoarthritis. These treatments defined as “conservative care” may be used in conjunction with oral NSAIDs and physical therapy. See 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 of a 2016 study in the American Journal of Sports Medicine states:
“Primary hip arthroscopy for all procedures performed in aggregate had excellent clinical outcomes and patient satisfaction scores at short-term follow-up in this study. More studies must be conducted to determine the definition of a successful outcome. There was a 6.1% minor complication rate, which was consistent with previous studies. Patients should be counseled regarding the potential progression of degenerative change leading to arthroplasty as well as the potential for revision surgery..”
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.
- Nearly 17% of the patients who had hip arthroscopy went in for a second surgery within two years. Two surgeries – two years.(2)
The researchers of this study were right to point out: More studies must be conducted to determine the definition of a successful outcome.
This research should concern patients thinking of a surgery for removal of their hip labrum
If the above research was not enough, listen to what doctors at the Rizzoli Orthopaedic Institute in Italy published in the medical journal Hip International:
In their research the Italian researchers wanted to examine the kinematic behavior of the hip joint (how the hip moved) with particular interest in the contribution of the periarticular soft tissues (tendons, ligaments, labral tissue) to hip stability. In essence to examine what happens to the hip when the acetabular labrum is damaged and then surgical repaired.
- After a series of tests to manipulate the hip through its natural range of motion, the doctors found that the “ball” of the ball and socket hip joint, the femoral head, was displacement in all directions and rotated into and out of its socket.
- Further, as surgery removed more tissue, the more unstable and “dislocated,” the hip became.
The study showed that after hip labrum surgery, the hip no longer acts as a ball-and-socket joint (meaning it is unstable and unsupportive for the rest of the body) and the femoral head anatomical displacement is strongly affected by the removal of periarticular soft tissues, labral repair as well as labrectomy.(4)
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.
- So, when a patient tells us that they are considering hip labrum surgery or hip labrectomy, and ask us what is the recovery time of these surgeries? We point to the studies above and tell them, there is no recovery from a hip labrum surgery.
Another study: Concerns about hip labrum MRI and surgical recommendation
If the above research was not enough, listen to what doctors at the David Geffen School of Medicine at UCLA wrote in the medical journal Skeletal radiology. This should concern patients over the age of 50 who had a MRI or MRA 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 magnetic resonance arthrography (MRA). . . “(4)
Basically the surgeons wanted to do hip labrum surgery, and are seeking and MRA (A more advanced imaging than MRI where contrast is used), to justify the surgery.
The radiologists of this study said this:
- “Given the high frequency of labral pathology and the questionable efficacy of arthroscopic surgical intervention in older patients, MR arthrography should be primarily for those with minimal arthritis on radiograph and potential to benefit from surgery. If further imaging beyond radiographs is necessary in these patients, standard MRI may be a more appropriate imaging tool.”(4)
In other words, in patients over 50 advanced imaging and surgery is not supported.
Please see our article Options and alternatives to hip preserving arthroscopic surgery
In a recent study published in Clinical orthopaedics and related research from doctors at the University Hospitals of Geneva and University of Geneva, concern is expressed 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.
What is being suggested here is that there was a thought that if you shaved away the damaged labrum tissue that regeneration of the acetabular labrum was possible. But studies are inconclusive and one study says it does not happen.
The Geneva team concluded: “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)
Doctors at The Ottawa Hospital in Canada found similar findings in their research published in The Journal of bone and joint surgery. They too cast a harsh light on hip labral procedures in patients over 45:
- “Arthroscopic labral debridement in patients forty-five years of age or older was associated with a relatively high reoperation rate and minimal overall improvement in joint-specific and quality-of-life outcome measures.
- Although differences in some outcome measures were statistically significant, most did not reach the level of the minimum clinically important difference.
- Arthroscopic debridement of labral tears in this patient population must be approached with caution as the overall clinical benefit was small.”(6)
Surgeons discuss saving the hip labrum
Doctors at the Ohio State University Wexner Medical Center say in their research in the Sports medicine and arthroscopy review: that the techniques utilized for the management of articular cartilage and hip labral injuries during hip preservation surgery have changed dramatically because doctors need to figure out a way to preserve the hip labrum so as to achieve the goal of providing labral treatment that restores native functions of the labrum to allow for more normal biomechanical function.(7)
In 2009, Dr. Megan M. Groh of the Physical Medicine & Rehabilitation, Mount Sinai Hospital, New York. 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. Writing in the Current Reviews in Musculoskeletal Medicine:
- “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)
It all comes back to saving the hip labrum, as documented by the research
Research out of Wake Forest University School of Medicine published in the Journal of hip preservation surgery suggests that an awareness of how biomaterials, among them stem cells would make the future of hip arthroscopy exciting. 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)
Prolotherapy for Hip Labrum Tears
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.
Regenerative Injection Therapy (Prolotherapy) for Hip Labrum Lesions: Rationale and Retrospective Study
Ross Hauser MD of Caring Medical and Rehabilitation Services and Amos Z. Orlofsky, Ph.D of Albert Einstein College of Medicine published the above study in The Open Rehabilitation Journal research describing the effectiveness of Prolotherapy for hip labral tear and groin pain. The study concluded Prolotherapy for acetabular labral tear appears to be a safe and potentially effective treatment.
Here are learning points from that research:
- The results of the study were encouraging, as all 19 patients reported pain reduction and all reported improvement in at least one of two functional categories.
- All patients expressed a positive view of their treatment on (self-reported) questionnaire. Improvements appeared to
be stable during at least the first two years post-treatment, as judged by the lack of time dependence for pain reduction.
- (Prolotherapy) was well tolerated and no adverse events were observed.
- The study results are notable for the high frequency of posttreatment reports of complete symptomatic relief, rather than
- Hypertonic dextrose potentially has multiple effects that may enhance labral healing, including the induction of growth factor production and proliferative responses as well as the possible elicitation of inflammatory changes that may promote healing responses.
- The nature of healing responses in the labrum is still poorly understood, but earlier studies suggest that considerable
spontaneous healing occurs and that therapies that focus on amplifying and optimizing this spontaneous process may have merit.
- Given the poor efficacy of current conservative treatment of labral tear, and the risks, failure rate and expense associated with arthroscopy, regenerative therapy may be viewed as a potential adjunct to conservative management.(10)
A Retrospective Study on Hackett-Hemwall Dextrose Prolotherapy for Chronic Hip Pain at an Outpatient Charity Clinic in Rural Illinois
In this research published in the Journal of Prolotherapy, 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.10
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.”(11)
If you have questions about Hip Labrum Surgery, You can get help and information from our Caring Medical staff
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