Reported Rates of Labral Repair and Reconstruction in Primary Hip Arthroscopy Vary Widely Across Published Studies: A Systematic Review

Purpose

To perform a systematic review to evaluate the reported proportions of labral repair and reconstruction performed during primary hip arthroscopy.

Methods

A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines by searching PubMed, the Cochrane Library, and Embase to identify studies, published from 2015 to October 2024, on primary hip arthroscopy reporting a number of hips undergoing labral repair versus reconstruction. When labral debridement was performed, these numbers were included as well. The search phrase used was: hip AND arthroscopy AND labral AND repair AND reconstruction . Outcomes reported were the numbers of labral repairs, reconstructions, and debridements in each study.

Results

Seven studies (all Level III) met the inclusion criteria with a total of 4,134 hips undergoing primary hip arthroscopy. Mean patient age ranged from 28.4 to 43.7 years, and the overall percentage of male patients ranged from 11.8% to 52.8% across studies. Procedures were carried out by a total of 13 surgeons. The proportion of cases in which labral repair was performed ranged from 25.7% to 86.9% across studies. Overall, 3,184 labral repairs, 902 labral reconstructions, and 48 selective labral debridements were performed. These procedures represented 25.6% to 86.9%, 13.1% to 21.8%, and 0.0% to 5.5% of procedures, respectively.

Conclusions

Among studies reporting labral repair and reconstruction during primary hip arthroscopy, the proportion of each procedure performed varies widely. These findings highlight the procedural heterogeneity across surgeons performing hip arthroscopy.

Level of Evidence

Level III, systematic review of level III studies.

The acetabular labrum surrounds the hip joint, enhancing stability, distributing joint load, and creating a tight seal to retain synovial fluid. In cases of mechanical disruptions such as femoroacetabular impingement, the labrum can progressively degenerate, leading to pain, disability, and potentially arthritis if untreated. Labral tears traditionally have been managed with arthroscopic debridement. However, a deeper understanding of the acetabular labrum’s role in hip joint biomechanics has shifted the focus toward conserving and restoring normal labral function as a central goal in hip preservation surgery. Although labral repair has shown improved function and favorable outcomes over debridement, extensive or complex tears are often unsuitable for repair.

Recently, labral reconstruction has emerged as a technique for addressing irreparable labra, which is thought to restore the labral suction seal, helping to reestablish the natural biomechanics of the hip joint. ^, Furthermore, the labrum contains a high concentration of pain-sensitive free nerve endings, so full resection of damaged labral tissue may offer greater pain relief. Segmental labral reconstruction initially was described by Philippon et al. in 2010, but circumferential reconstruction also can be performed for global acetabular overcoverage and labral ossification. Domb et al. reported that patient-reported outcomes (PROs) improved more in patients undergoing labral reconstruction compared with labral resection. These findings suggest that labral reconstruction can lead to favorable clinical outcomes, highlighting the importance of preserving labral function. ^,

Given the novelty of this procedure and the variations in general practice, it is unclear how often labral repair, when compared with reconstruction, is generally performed in primary hip arthroscopy cases. The purpose of this study was to perform a systematic review to evaluate the reported proportions of labral repair and reconstruction performed during primary hip arthroscopy. Caution was used to avoid any inferences to population-level proportions of procedures. The authors hypothesized that there would be significant heterogeneity in procedural case numbers within the current body of literature regarding primary hip arthroscopy.

Methods

This systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using a PRISMA checklist ( Fig 1 ). Two independent reviewers (P.G., J.D.) searched PubMed, Embase, and the Cochrane Library up to October 26, 2024. The electronic search strategy used was hip AND arthroscopy AND labral AND repair AND reconstruction . A total of 296 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 were studies published from 2015 to October 26, 2024, on primary hip arthroscopy reporting both numbers of hips undergoing labral repair and labral reconstruction. Studies published from 2015 onward were selected to capture contemporary literature from the period in which labral reconstruction became more widely described. Although some included studies may have included procedures from before 2015, these were retained because they met inclusion criteria and included both repair and reconstruction cohorts. Studies were excluded if they included revision hip arthroscopy, were published before 2015, or were matched cohort studies rather than a consecutive series of patients. In addition, if multiple studies were found from the same author with overlapping patient cohorts, the study with the greatest number of hips was included while the others were excluded. Data extraction from each study was performed independently and then reviewed by a third author (M.J.K.). There was no need for funding or a third party to obtain any of the collected data.

Image, AltText currently not available — Fig 1

A battery of statistical analyses were performed to help evaluate the strength of included studies. Although clinical outcomes from the studies were not pooled and reported, the authors found these analyses critical to modeling appropriate and complete evaluation of the literature regarding primary hip arthroscopy. Risk of bias was assessed according to the ROBINS-I (Risk Of Bias In Non-randomized Studies of Interventions) risk of bias tool, which incorporates an assessment of bias attributable to confounding, selection of participants, deviations from intended interventions, completeness of outcomes data, selection of outcomes reported, and other sources of bias. Two reviewers (P.G., J.D.) independently extracted the number of patients who underwent labral repair, debridement, or reconstruction during primary hip arthroscopy from each included study. The Cohen kappa statistic was calculated to assess interobserver agreement in the categorization of labral procedure type. A score of <0.20 indicates poor agreement; 0.21-0.40, fair agreement; 0.41-0.60, moderate agreement; 0.61-0.80, good agreement; 0.81-1.00, very good agreement.

Data Extraction and Evaluation

Data extracted from each study included the level of evidence; country of authorship; number of hips undergoing labral repair, reconstruction, or debridement; number of surgeons involved in each study; and patient sex, age, and body mass index. Forest plots were constructed to evaluate differences and consistency of the proportion of labral repairs, reconstructions, and debridement ( Fig 2 ). R, version 4.3.2 was used for analysis and the “meta” and “metafor” packages were used for all meta-analysis modeling and plot construction. The variance-stabilizing Freeman-Tukey double arcsine transformation was applied to those proportions to ensure stable estimation of effects. Since the purpose of this study was not to explicitly evaluate heterogeneity, I ² is reported, but overall random and common estimates for proportions of procedures are omitted. For clarity, tau is also omitted. For all studies, weights are assigned using the inverse variance method.

Study Methodology Assessment

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.

Results

Eight studies met inclusion criteria ( Table 1 ). ^,^,^,^,^,^,^, Two studies included an overlapping cohort of patients ^, ; therefore, the study with the greater number of patients was included in our review. A total of 4,134 hips were included ( Table 2 ). Mean age ranged from 28.4 to 43.7 years, and the overall percentage of male patients ranged from 11.8% to 52.8% across studies. Although the study publication dates ranged from 2017 to 2024, the hip arthroscopies reported on in these studies occurred from 2006 to 2020. Procedures were carried out by a total of 13 surgeons.

Table 1

Summary of Included Studies With Characteristics

Study	Principal Investigator	Country	Level of Evidence	Decision-Making	Number of Surgeons	Years of Procedures
Nakashima et al., 2019	Uchida	Japan	III	Algorithm	1	2009-2014
Vogel et al., 2022	Mei-Dan	U.S.A.	III	Surgeon preference	1	2013-2020
White et al., 2020	Herzog	U.S.A.	III	Surgeon preference	1	2010-2015
Matsuda et al., 2018	Carreira	U.S.A.	III	Surgeon preference	7	2014-2016
Scanaliato et al., 2022	Wolff	U.S.A.	III	MASH/Beck classification	1	2015
Maldonado et al., 2020	Domb	U.S.A.	III	Surgeon preference	1	2010-2018
Dornan et al., 2024	Philippon	U.S.A.	III	Surgeon preference	1	2006-2018

MASH, Multicenter Arthroscopic Study of the Hip.

Table 2

Summary of Study Procedures

Study	Total Hips (n = 4,134)	Labral Repair (n = 3,184)	Labral Reconstruction (n = 902)	Labral Debridement (n = 48)
Nakashima et al., 2019	151	126 (83.4%)	25 (16.6%)	−
Vogel et al., 2022	68	59 (86.8%)	9 (13.2%)	−
White et al., 2020	363	93 (25.6%)	270 (74.4%)	−
Matsuda et al., 2018	876	693 (79.1%)	135 (15.4%)	48 (5.5%)
Scanaliato et al., 2022	130	68 (52.3%)	62 (47.7%)	−
Maldonado et al., 2020	1,398	1,147 (82.1%)	251 (18.0%)	−
Dornan et al., 2024	1,148	998 (86.9%)	150 (13.1%)	−