Protected Weight-Bearing and Early Passive Mobilization Are Common Components of Rehabilitation After Hip Arthroscopy With Labral Reconstruction

Purpose

To perform a systematic review of postoperative rehabilitation protocols after hip arthroscopy with labral reconstruction.

Methods

A systematic review was conducted by searching PubMed, the Cochrane Library, and Embase databases for studies reporting postoperative rehabilitation protocols after hip arthroscopy with labral reconstruction. Inclusion criteria were clinical studies detailing rehabilitation protocols after hip arthroscopy with primary labral reconstruction. Studies were excluded if they involved revision procedures, lacked rehabilitation protocols, or were nonclinical reports. The search terms used were: hip labral reconstruction . Extracted data included initial weight-bearing (WB) status, time to full WB, use of continuous passive motion (CPM), initial range of motion limitations, brace use and duration, physical therapy modalities, return-to-sports timing, patient-reported outcome measures, and reoperation rates, defined as the need for revision arthroscopy or conversion to total hip arthroplasty.

Results

Twenty studies, including 641 patients, met inclusion criteria. The mean patient age ranged from 32.0 to 43.7 years, with mean follow-up durations ranging from 0.6 years to 6.4 years. Four studies allowed WB as tolerated, one required non-WB, whereas 15 studies implemented protected WB (i.e., partial WB or touch-down WB) postoperatively, with all studies allowing full WB within 8 weeks. CPM was initiated within 12 to 24 hours postoperatively in 6 studies. Hip immobilization devices were used in 6 studies. Five studies reported range of motion restrictions, limiting hip flexion anywhere from 30° to 90°. Fourteen studies reported 11 unique patient-reported outcome measures and 55% of all studies reported reoperation rates. Among 5 studies that reported return-to-sport timelines, 4 (80%) permitted return by 6 months. Although most protocols discussed physical therapy and strength progression, considerable variability existed regarding exercise timing and initiation.

Conclusions

This systematic review highlights the heterogeneity in postoperative rehabilitation protocols after hip arthroscopy with labral reconstruction, reflecting a lack of standardized, evidence-based guidelines.

Level of Evidence

Level V, systematic review of Level II-V studies.

The acetabular labrum stabilizes the hip by deepening the joint and preventing lateral and vertical motion of the femoral head. In addition, it maintains the hip fluid seal, which preserves negative pressure, reduces microinstability, and protects the articular cartilage. ^, However, if the labrum is disrupted, this increases the contact stresses within the hip, leading to early cartilage damage. ^, This shows the importance of labral reconstruction in restoring the fluid seal and reducing the intra-articular contact stresses, as reported by Philippon et al., who found labral reconstruction restored hip pressure similar to that of the intact state. On the basis of this research, there has been a growing number of recent studies ^,^,^,^, advocating for labral reconstruction in cases of irreparable labral damage.

Hip arthroscopy has become a widely accepted and minimally invasive surgical technique for managing various intra-articular hip pathologies, including labral tears and femoroacetabular impingement syndrome. The indications for labral reconstruction are heterogeneous but may include segmental defects, “nonviable” labral tissue, a diminutive labrum, and failed previous labral repair. This procedure aims to restore joint biomechanics, improve stability, and alleviate pain, ultimately enhancing patient outcomes. In a recent systematic review, Curley et al. reported improved patient-reported outcomes measures (PROMs) in all studies reporting minimum 5-year outcomes after labral reconstruction. In lieu of the growing popularity in labral reconstruction and favorable patient-reported outcomes, the literature lacks a consensus on rehabilitation protocols.

Although labral reconstruction traditionally has been reserved for revision procedures, its use in primary settings is increasing, particularly in cases involving hypoplastic, calcified, or otherwise irreparable labral tissue. ^, Early studies established its utility in revision surgery, where the native labrum is often nonviable as a result of previous debridement or failed repair. ^, More recently, improved surgical techniques, graft options, and growing experience have led to broader indications, including primary reconstructions performed at the index operation when labral preservation and repair is not feasible. ^,^, As this technique continues to gain traction in both primary and revision settings, a clearer understanding of its associated rehabilitation protocols is warranted.

Currently, postoperative rehabilitation after labral repair typically includes partial weight-bearing (PWB) for 2 to 4 weeks with progression to weight-bearing as tolerated (WBAT) thereafter, although these protocols are largely determined on the basis of expert opinion. ^, Several biomechanical studies ^, have reported the ability of labral repair suture anchors to withstand the physiological loads of axial weight-bearing, supporting immediate full weight-bearing as another option. Given that labral reconstruction may offer less initial joint stability compared with repair, as seen in biomechanical studies, ^, more protective rehabilitation protocols may be warranted; however, evidence to support distinct guidelines remains limited.

Given the increasing prevalence of hip arthroscopy with labral reconstruction, a systematic understanding of existing rehabilitation protocols is essential to guide clinical practice and improve patient outcomes. The purpose of this study was to perform a systematic review of postoperative rehabilitation protocols after hip arthroscopy with labral reconstruction. The authors hypothesized that there would be heterogeneity in the postoperative rehabilitation protocols reported in the literature.

Methods

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using a Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Two independent reviewers (K.M., J.D.) searched PubMed, Embase, and the Cochrane Library up to January 4, 2025. The electronic search strategy entered into each aforementioned database was: hip labral reconstruction . A total of 1,248 studies were reviewed by title and/or abstract to determine study eligibility on the basis of inclusion criteria. Furthermore, reference lists for studies that met inclusion criteria were reviewed to see whether any further studies were identified that met inclusion criteria. In cases of disagreement, a third reviewer (M.J.K.) made the final decision. Inclusion criteria included any study reporting on a postoperative rehabilitation protocol after hip arthroscopy with primary labral reconstruction. Studies were excluded if they did not report on postoperative rehabilitation, patients undergoing revision hip arthroscopy, or nonclinical studies. If multiple studies had the same senior author, only the most recent study was included in order to represent the authors’ most recent rehabilitation practice. Data extraction from each study was performed by one author independently (K.P.M.) and then reviewed by a second author (M.J.K.). There was no need for funding or a third party to obtain any of the collected data, because the authors completed the data collection.

Study Methodology Assessment

Two authors (K.P.M., J.D.) used the Methodologic Index for Non-randomized Studies criteria to score all included articles. Articles were individually graded. Article score discrepancies were resolved by article review and discussion until unanimous consensus was found. Level of evidence standards set by Hohmann et al. were used for the articles.

The Modified Coleman Methodology Score (MCMS) was used to evaluate study methodology quality. The MCMS has a scaled potential score ranging from 0 to 100. Scores ranging from 85 to 100 are excellent, 70 to 84 are good, 55 to 69 are fair, and less than 55 are poor. The primary outcomes assessed by the MCMS are study size and type, follow-up time, attrition rates, number of interventions per group, and proper description of study methodology.

Data Extraction

Data extracted from each study included the various components of postoperative rehabilitation, such as initial weight-bearing (WB) status and time to full WB, use of postoperative bracing, initial hip range of motion (ROM), the use of continuous passive motion (CPM), the time to return-to-play (RTP), physical therapy modalities used with the timing of their initiation, PROMs, and reoperation rates, defined as the need for subsequent or revision arthroscopy or conversion to total hip arthroplasty.

Statistical Analysis

Descriptive statistics were used to summarize patient demographics and postoperative rehabilitation protocols. Continuous variables were reported as means with standard deviations, whereas categorical variables were presented as frequencies and percentages. Interstudy variability in rehabilitation protocols was analyzed qualitatively. Given the heterogeneity of the studies, trends across the studies were identified and various postoperative rehabilitation parameters were compared descriptively. Methodologic quality assessment scores were analyzed to evaluate study reliability, validity, and risk of bias.

Results

Twenty studies ^,^,^,^,^,^,^,^,^,^,^,^,^,^,^,^,^,^,^, met the inclusion and exclusion criteria ( Fig 1 ), including a total of 641 patients undergoing hip labral reconstruction. The mean patient age ranged from 32.0 to 43.7 years, and the mean follow-up duration ranged from 0.6 years to 6.4 years. The overall percentage of male subjects ranged from 20.7% to 77.1% and the mean body mass index ranged from 23.3 to 27.5 ( Table 1 ). Twenty-eight studies had overlapping senior authors, with similar rehabilitation protocols; therefore, only the most recent study from each of the senior authors was included in the results of our systematic review.

Image, AltText currently not available — Fig 1

Table 1

Patient Demographics

Study	LOE	N	Male, %	Age at Surgery, yr	BMI, kg/m ²	Follow-up, yr
DeFroda et al., 2023	V	NR	NR	NR	NR	NR
Singh et al., 2021	V	NR	NR	NR	NR	NR
Lee et al., 2022	IV	11	72.7	32 ± 5.9	26.5 ± 2.9	0.62
Tey-Pons et al., 2021	IV	3	66.7	40.3	NR	4
Rathi and Mazek, 2018	IV	7	71.4	35	NR	1.25
DeFroda et al., 2021	V	NR	NR	NR	NR	NR
Amar et al., 2018	IV	31	61.3	42.4	NR	2.65
Deshmane et al., 2013	V	2	50	33	NR	1
Park and Ko, 2013	V	1	0	43	NR	NR
Rath et al., 2017	V	NR	NR	NR	NR	NR
Scheidt et al., 2021	V	NR	NR	NR	NR	NR
Della Rocca et al., 2024	III	48	77.1	37.1 ± 7.3	25.1 ± 3.5	3.5 ± 1.5
Kocaoglu et al., 2022	II	42	33.3	32.5 ± 7.5	NR	2.8 ± 0.5
Maldonado et al., 2022	III	94	50	43.9 ± 9.8	27.45 ± 5.21	2.37 ± 0.62
Kucharik et al., 2021	IV	97	50.5	39	25.8	2.35
Matsuda et al., 2013	III	54	59.3	37.08 ± 13.07	27.50 ± 5.28	2.5
White et al., 2018	III	29	20.7	33.3 ± 11.0	NR	3.3
Scanaliato et al., 2022	III	62	37.1	38.3 ± 11.2	23.27 ± 3.3	5 ± 0.13
Dornan et al., 2024	III	129	67.4	38 ± 12	24.7 ± 3.6	6.4 ± 3.4
Carreira et al., 2018	IV	31	35.5	43.7 ± 9.2	24.2 ± 4.0	2.6 ± 0.59

NOTE. Sex is reported as a percentage. Age, BMI, and follow-up are reported as mean ± SD (if available).

BMI, body mass index; LOE, level of evidence; NR, not reported; SD, standard deviation.

Postoperative WB

All 20 studies ^,^,^,^,^,^,^,^,^,^,^,^,^,^,^,^,^,^,^, reported on postoperative WB status ( Table 2 ). Most studies ^,^,^,^,^,^,^,^,^,^,^,^,^,^,^,^,^, allowed some form of protected WB postoperatively, with full WB permitted by 8 weeks in all cases and by 6 weeks in 95% (19/20) of cases. One study required non−weight-bearing (NWB) for 6 weeks, whereas others ^,^,^,^,^,^,^,^,^,^,^,^,^, used PWB with varying weight limitations (i.e., 20%-50% body-weight or 20 lbs) for 3-6 weeks. A few studies ^,^,^, allowed WBAT immediately, often with crutch assistance.

Table 2

Postoperative WB, PROMs, and Reoperation Rate

Study	Initial WB Status	Progression to FWB	PROMs	Reoperation Rate, %
DeFroda et al., 2023	Flat-foot WB minimum 2 weeks 50% WB with crutches ×1 wk 100% WB with crutches ×1 wk Progress to 100% without crutches at 5-6 wk	5-6 wk	NR	NR
Singh et al., 2021	Flat-foot WB (20 lbs) with crutches	3 wk	NR	NR
Lee et al., 2022	Touchdown WB	4 wk	VAS Pain	0.0
Tey-Pons et al., 2021	50% body weight	3 wk	NAHS, HOS-ADL	NR
Rathi and Mazek, 2018	Flat-foot WB (20 lbs) ×3 wk Wean off crutches ×1 wk	4 wk	mHHS, Satisfaction	0.0
DeFroda et al., 2021	Flat-foot WB (20 lbs) with crutches	3 wk	NR	NR
Amar et al., 2018	WBAT	Immediately if patient felt stable and pain diminished	mHHS	2.0
Deshmane et al., 2013	NWB	6 wk	NR	NR
Park and Ko, 2013	No WB status specified initially. Start PWB at week 6 Start full WB at week 8	8 wk	mHHS, WOMAC	NR
Rath et al., 2017	Eight surgeons allow immediate WBAT 1 surgeon: WB at 1 wk 8 surgeons: WB at 3 wk 1 surgeon: WB at 8 wk	Immediate	NR	NR
Scheidt et al., 2021	PWB (20 lbs)	6 wk	NR	NR
Della Rocca et al., 2024	PWB (50%) with crutches	4 wk	mHHS, NAHS, HOS, HOS-SS, iHOT-12, VAS Pain, Satisfaction	2.0
Kocaoglu et al., 2022	PWB	4 wk	mHHS, NAHS, HOS-SS, VAS Pain	0.0
Maldonado et al., 2022	20-lb WB restriction	6 wk	mHHS, NAHS, HOS-SS, iHOT-12, VAS Pain, SF-12 P, SF-12 M, VR-12 P, VR-12 M, Satisfaction	11.7
Kucharik et al., 2021	WBAT flat-foot gait with crutches	6 wk	mHHS, HOS-SS, iHOT-33	NR
Matsuda et al., 2013	Crutch-protected WB	2 wk	NAHS	0.0
White et al., 2018	30% WB	4 wk	mHHS, VAS Rest, VAS ADLs, VAS Sport, LEFS	13.7
Scanaliato et al., 2022	WBAT	Immediately, crutches for 4 wk	mHHS, iHOT-12, VAS Pain, VAS Satisfaction	6.5
Dornan et al., 2024	20-lb foot-flat WB	4 wk	mHHS, HOS-SS, HOS-ASL, WOMAC, SF-12 P, SF-12 M	30.2
Carreira et al., 2018	20-lb WB restriction	4 wk	mHHS, HOS-SS, HOS-ADL, iHOT-12, SF-12 P, SF-12 M	12.9

ADL, activities of daily living; FWB, full weight-bearing; HOS, Hip Outcome Score; HOS-ADL, Hip Outcome Score–Activities of Daily Living; HOS-SS, Hip Outcome Score–Sports Specific; iHOT, International Hip Outcome Tool; LEFS, Lower Extremity Functional Scale; mHHS, Modified Harris Hip Score; NAHS, Non-Arthritic Hip Score; NWB, non−weight-bearing; PROM, patient-reported outcome measure; PWB, partial weight-bearing; SF-12 M, 12-Item Mental Short Form Health Survey; SF-12 P, 12-Item Physical Short Form Health Survey; VAS Pain, visual analog scale for pain; VR-12 M, Veterans RAND 12-Item Mental Health Survey; VR-12 P, Veterans RAND 12-Item Physical Health Survey; WB, weight-bearing; WBAT, weight-bearing as tolerated; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index.

Postoperative Bracing

Six studies ^,^,^,^,^, used a hip immobilization device to limit ROM to specific ranges (i.e., 0-90° of flexion) postoperatively for all patients ( Table 3 ). A hip brace was used for 3 weeks ^, or 6 weeks. ^, Two studies ^, used an anti-rotation bolster to prevent hip external rotation at rest for 3 weeks. None of the studies gave explicit instructions on brace use, except for the parameters listed in Table 3 .

Table 3

CPM, Hip Immobilization, and Hip ROM

Study	Duration of CPM	Immobilization Type	Immobilization Duration	Initial ROM
DeFroda et al., 2023	NR	NR	NR	NR
Singh et al., 2021	NR	NR	NR	NR
Lee et al., 2022	NR	NR	NR	F: 90° ER: 0° Neutral rotation with ER only allowed during resting positions.
Tey-Pons et al., 2021	NR, but used	NR	NR	NR
Rathi and Mazek, 2018	6-8 h/4 wk	NR	NR	NR
DeFroda et al., 2021	NR	Hip brace	3 weeks	NR
Amar et al., 2018	NR	NR	NR	NR
Deshmane et al., 2013	NR	Hip spica brace	6 wk	F: 30°
Park and Ko, 2013	NR/6 wk	Hip brace	3 wk	Brace to limit extension and IR/ER.
Rath et al., 2017	NR	NR	NR	NR
Scheidt et al., 2021	NR	NR	NR	NR
Della Rocca et al., 2024	NR/4 wk	NR	NR	F: 90° Avoid excessive IR/ER. Then, gradually increased until full recovery.
Kocaoglu et al., 2022	NR	NR	NR	NR
Maldonado et al., 2022	NR	Hip brace	6 wk	F: 0-90°
Kucharik et al., 2021	NR	NR	NR	NR
Matsuda et al., 2013	NR	NR	NR	NR
White et al., 2018	NR	NR	NR	NR
Scanaliato et al., 2022	NR	NR	NR	NR
Dornan et al., 2024	6-8 h/4 wk	Anti-rotation bolster	3 weeks	NR
Carreira et al., 2018	4-6 h/4 wk	Anti-rotation bolster	3 weeks	NR