Circumferential Acetabular Labral Reconstruction for Irreparable Labral Tears in The Primary Setting: Minimum Two-Year Outcomes with a Nested Matched-Pair Control

Journal Pre-proof Circumferential Acetabular Labral Reconstruction for Irreparable Labral Tears in The Primary Setting: Minimum Two-Year Outcomes with a Nested Matched-Pair Control David R. Maldonado, MD, Cynthia Kyin, BA, Philip J. Rosinsky, MD, Jacob Shapira, MD, Mitchell J. Yelton, BS, Mitchell Meghpara, MD, Ajay C. Lall, MD, MS, Benjamin G. Domb, MD PII:

S0749-8063(20)30155-9

DOI:

https://doi.org/10.1016/j.arthro.2020.02.014

Reference:

YJARS 56810

To appear in:

Arthroscopy: The Journal of Arthroscopic and Related Surgery

Received Date: 9 September 2019 Revised Date:

4 February 2020

Accepted Date: 5 February 2020

Please cite this article as: Maldonado DR, Kyin C, Rosinsky PJ, Shapira J, Yelton MJ, Meghpara M, Lall AC, Domb BG, Circumferential Acetabular Labral Reconstruction for Irreparable Labral Tears in The Primary Setting: Minimum Two-Year Outcomes with a Nested Matched-Pair Control, Arthroscopy: The Journal of Arthroscopic and Related Surgery (2020), doi: https://doi.org/10.1016/j.arthro.2020.02.014. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier on behalf of the Arthroscopy Association of North America

Circumferential Labral Reconstruction for Irreparable Labral Tears in The Primary Setting: Minimum Two-Year Outcomes with a Nested Matched-Pair Control

Running Title: Circumferential Labral Reconstruction David R. Maldonado, MD1 Cynthia Kyin, BA1 Philip J. Rosinsky, MD1 Jacob Shapira, MD1 Mitchell J. Yelton, BS1 Mitchell Meghpara, MD1,3 Ajay C. Lall, MD, MS1,2 Benjamin G. Domb, MD1,2* David R. Maldonado, MD Cynthia Kyin, BA Philip J. Rosinsky, MD Jacob Shapira, MD Mitchell J. Yelton, BS Mitchell Meghpara, MD Ajay C. Lall, MD, MS Benjamin G. Domb, MD

[email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected]

Author Affiliations: 1. American Hip Institute Research Foundation, Des Plaines, IL 60018 2. American Hip Institute, Des Plaines, IL 60018 3. AMITA Health St. Alexius Medical Center, Hoffman Estates, IL 60169 This study was performed in accordance with the ethical standards in the 1964 Declaration of Helsinki. This study was carried out in accordance with relevant regulations of the US Health Insurance Portability and Accountability Act (HIPAA). Details that might disclose the identity of the subjects under study have been omitted. This study was approved by the IRB. (IRB ID: 5276) One of the authors certifies that he (BGD), or a member of his immediate family, has or may receive payments or benefits, during the study period, an amount of USD 100,001–USD 1,000,000 from Arthrex Inc (Naples, FL, USA); an amount of USD 10,000–USD 100,000 from DJO Global Inc (Vista, CA, USA); an amount of USD 10,000–USD 100,000 from Medacta International (Chicago, IL, USA); an amount of less than USD 10,000 from Orthomerica Products Inc (Orlando, FL, USA); an amount of less than USD 10,000 from Pacira Pharmaceuticals Inc (Parsippany-Troy Hills, NJ, USA); an amount of less than USD 10,000 from Medwest Associates (Chicago, IL, USA); an amount of less than USD 10,000 from Prime Surgical, LLC (Vestavia, AL, USA); an amount of less than USD 10,000 from Trice Medical, Inc. (Malvern, PA, USA); an amount of less than USD 10,000 from Smith & Nephew, Inc. (London, UK); and an amount of USD 100,001–USD 1,000,000 from Stryker Corporation (Kalamazoo, MI, USA). One of the authors certifies that he (ACL), or a member of his immediate family, has or may receive payments or benefits, during the study period, an amount of USD 10,000–USD 100,000 from Arthrex Inc

(Naples, FL, USA); an amount of less than USD 10,000 from Medwest Associates (Chicago, IL, USA); an amount of USD 10,000–USD 100,000 from Smith & Nephew, Inc (London, UK); an amount of less than USD 10,000 from Stryker Corporation (Kalamazoo, MI, USA); and an amount of less than USD 10,000 from Zimmer Biomet Holdings, Inc (Warsaw, IN, USA).

All authors have participated in the preparation of this manuscript, are in agreement with its contents, and agree to be accountable for all aspects of the work and its accuracy. David R. Maldonado, MD. - Data collection/analysis and writing of the manuscript Cynthia Kyin, BA. - Data collection/analysis and writing of the manuscript Philip J. Rosinsky, - MD. Data collection/analysis and writing of the manuscript Jacob Shapira, MD. - Data collection and revision of the manuscript Mitchell J. Yelton, BS. - Data collection and revision of the manuscript Mitchell Meghpara, MD. - Data collection and revision of the manuscript Ajay C. Lall, MD, MS. – Data interpretation and revision of manuscript Benjamin G. Domb, MD. - Data interpretation and revision of manuscript

*Corresponding Author: Dr. Benjamin G. Domb 999 E Touhy Ave Suite 450 Des Plaines, IL 60018 Phone: +1 630 455 7130 Fax: +1 630 323 5625 Email: [email protected] This study was performed at the American Hip Institute.

1

Circumferential Acetabular Labral Reconstruction for Irreparable Labral

2

Tears in The Primary Setting: Minimum Two-Year Outcomes with a Nested

3

Matched-Pair Control

4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

19

Abstract

20

Purposes: (1) To report minimum two-year patient-reported outcome score (PROs) of primary

21

circumferential acetabular labral reconstruction using anterior tibialis allograft and the knotless

22

pull-through technique in the setting of femoroacetabular impingement syndrome (FAIS) and

23

irreparable labral tears and (2) to compare these PROs to a matched-pair primary labral repair

24

group.

25

Methods: Data were prospectively collected and retrospectively reviewed. Patients were

26

included if they underwent primary circumferential labral reconstruction using anterior tibialis

27

tendon allograft during January 2016 to March 2017 for irreparable labral tears and FAIS, had

28

postoperative scores for the modified Harris Hip Score (mHHS), Hip Outcome Score Sports-

29

Specific (HOS-SSS), Non-Arthritic Hip Score (NAHS), International Hip Outcome Tool (iHOT-

30

12), 12-item Short From Health Survey both Physical and Mental components, Veterans RAND

31

12 Item Health Survey both Physical Mental, and visual analog scale (VAS) for pain, that were

32

collected at three-months and then annually Exclusion criteria were previous ipsilateral hip

33

conditions or surgeries, Tönnis grade ≥ 2, or dysplasia (lateral center-edge angle < 18°). Labral

34

tears were considered irreparable if the labrum appeared 1) to be mostly or completely calcified,

35

2) to be inadequate (nonviable) and not amenable for labral repair. The reconstruction group was

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matched 1:3 to a benchmark control group of labral repairs based on age, gender, and body mass

37

index from the same time period. Minimal Clinically Important Difference (MCID) and Patient

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Acceptable Symptomatic State (PASS) for mHHS and iHOT-12 were calculated.

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Results: Thirty-seven hips (37 patients) underwent circumferential labral reconstruction.

40

Nineteen (51.4%) were females, and 18 (48.6%) were males. Mean age was 45.6 ± 11.6 years,

41

and average body-mass index was 27.1 ± 5 kg/m2. At minimum two-year follow-up, the

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circumferential labral reconstruction group demonstrated statistically significant improvements

43

for mHHS, NAHS, HOS-SSS, iHOT-12, VAS. All hips in the reconstruction group were

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successfully matched to 111 labral repair hips. At latest follow-up, improvements for all PROs

45

between the two groups were comparable. The revision rate was 0% and 3.6% for the

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reconstruction and repair groups respectively.

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Conclusions: Following primary hip arthroscopy, primary circumferential labral reconstruction

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utilizing anterior tibialis allograft and the knotless pull-through technique in the setting of FAIS

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and irreparable labral tears resulted in significant improvement in several PROs at minimum

50

two-year follow-up and patient satisfaction. Primary circumferential labral reconstruction

51

reached comparable functional outcomes when compared to a benchmark matched-pair primary

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labral repair control group.

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Level of Evidence: Level III, Case-Control study.

54 55 56 57 58 59 60 61 62

63 64

Introduction Labral tears remain one of the most common findings in hip arthroscopy surgery, and

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restoration of labral function has been established as a vital factor for normal biomechanics and

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favorable patient-reported outcomes (PROs) in the long-term.1–3 Previously, the intervention of

67

choice has been labral repair with some data suggesting labral debridement under narrow

68

indications.4,5 Until recently, complete labral debridement (resection) was the only feasible

69

option for cases of irreparable labral tears, Figure 1. However, with greater understanding of the

70

labrum anatomy and function in addition to advancements in technology, labral reconstruction

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has become a valid option. Current data has supported labral reconstruction and more recently

72

labral augmentation as alternatives to restore labral function.1,6–8

73

Reconstruction of the irreparable labral segment or “segmental reconstruction” with a

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graft was initially described in the open and then arthroscopic fashion.9,10 More recently, diverse

75

techniques including arthroscopic segmental and circumferential labral reconstruction have been

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proposed, Figure 2 and 3.11,12 Nonetheless, most of the available data reporting on short- and

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mid-term outcomes of labral reconstruction is based on the segmental technique.6,13,14

78

The purposes of this study were as follows (1) to report minimum two-year PROs of

79

primary circumferential acetabular labral reconstruction using anterior tibialis allograft and the

80

knotless pull-through technique in the setting of femoroacetabular impingement syndrome

81

(FAIS) and irreparable labral tears and (2) to compare these PROs to a matched-pair primary

82

labral repair group. The authors hypothesized that patients who underwent arthroscopic primary

83

circumferential labral reconstruction would have significant improvements in PROs and high

84

patient satisfaction. Furthermore, improvement between the primary labral reconstruction group

85

and matched control primary labral repair group would be comparable.

86 87

Methods

88

Patient Selection Criteria

89

Data were prospectively collected and retrospectively reviewed for all patients who

90

underwent a hip arthroscopy at our institution from February 2016 to April 2017. Patients were

91

included in the study if they underwent either a labral repair or a circumferential labral

92

reconstruction using anterior tibialis tendon allograft and had preoperative outcome scores for

93

following PROs: the modified Harris Hip Score (mHHS),15 Non-Arthritic Hip Score (NAHS),16

94

Hip Outcome Score Sports-Specific (HOS-SSS),17 International Hip Outcome Tool (iHOT-12),18

95

12-item Short Form Health Survey both Physical and Mental components (SF-12 P and SF-12

96

M),19 Veterans RAND 12 Item Health Survey both Physical Mental (VR-12 P and VR-12 M),20

97

and visual analog scale (VAS) for pain.21 Patients were excluded if they had a prior ipsilateral

98

hip condition (Perthes disease, slipped capital femoral epiphysis, inflammatory arthritis, or

99

avascular necrosis), a previous ipsilateral hip surgery, a preoperative Tönnis grade ≥ 2, or hip

100

dysplasia defined as a lateral center-edge angle (LCEA) ≤18°.22 Patients were considered to have

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complete follow-up if they had an end-point procedure such as a revision hip arthroscopy or

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converted to a total hip arthroplasty (THA). If they did not undergo a secondary surgery,

103

minimum follow-up was set at two-years, and patients were also required to have all PROs in

104

addition to patient satisfaction rated on a 0-to-10 scale. This study was approved by the

105

institutional review board.

106 107

Participation in the American Hip Institute Hip Preservation Registry

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All patients participated in the American Hip Institute Hip Preservation Registry. While

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the present study represents a unique analysis, data on some patients in this study may have been

110

reported in other studies.4,23

111 112

Primary Circumferential Labral Reconstruction Group and Primary Labral Repair

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Control Group Matching Process

114

Propensity score matching was conducted using R (Version 3.4.0; R Foundation for

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Statistical, Vienna, Austria).24 The propensity scoring techniques were used to minimize the

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effect of potential confounding variables between the circumferential reconstruction and the

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repair control groups.25,26 Patients in the circumferential group were matched based on age,

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gender, and body mass index (BMI) to patients in the repair control group from the same time

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frame in a 1 : 3 ratio using greedy matching without replacement. Thus, if a patient in the repair

120

group was matched to a patient in the circumferential group, they were not re-matched to a

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different circumferential patient. Using greedy matching without replacement has been

122

established in the literature as the optimal method for estimating differences between groups.25

123 124 125

Clinical Evaluation All included patients underwent a comprehensive physical examination including

126

assessments of range of motion and signs of FAIS indicated by positive lateral, anterior, and

127

posterior impingement tests by the senior surgeon (B.G.D).27 As a tool for surgical planning, all

128

patients underwent preoperative radiographic imaging. Included views were a 45° modified

129

Dunn view, a false-profile view, and an anteroposterior pelvis view in the upright and supine

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positions.28 Images were then assessed using the Tönnis classification for osteoarthritis.29

131

Anterior center-edge angle (ACEA) and LCEA were used for acetabular coverage

132

assessment.30,31 The alpha angle was measured according to the method in Nötzli et al., and an

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alpha angle > 55° was indicative of a cam-type morphology.32 Additionally, labral tears and

134

other potential extra- and intra-articular defects were determined using magnetic resonance

135

arthrography for all patients.

136 137

Indications for Surgical Treatment

138

All patients underwent a minimum of three months of non-surgical treatment including

139

rest, nonsteroidal anti-inflammatory medications, and physical therapy before being considered

140

for surgical management. If the patient failed conservative measures and continued to have

141

symptoms indicated by FAIS and labral tears, they were recommended by the senior author

142

(X.X.X) for arthroscopic surgery.33

143 144

Indications and Surgical Technique For Primary Circumferential Labral

145

Reconstruction

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All patients were placed in the supine position on a traction extension table with a padded

147

perineal post and draped in conventional sterile fashion.34,35 For all patients who required a

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circumferential labral reconstruction, four portals were established: standard anterolateral,

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midanterior, distal anterior accessory, and posterolateral.11,36 Interportal capsulotomy using a

150

beaver blade was performed to gain access to the hip joint. Incisions were made parallel to the

151

labrum using direct visualization.37 A diagnostic arthroscopy was then performed to evaluate the

152

labrum, intra-articular cartilage, and ligamentum teres. The acetabular labrum articular

153

disruption (ALAD) and Outerbridge classifications were used to grade acetabular chondral

154

defects.38,39 Seldes classification was used to grade labral tears,40 and the Domb and Villar

155

classifications were used for the ligamentum teres.41

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Concomitant procedures were also performed if indicated. Under fluoroscopic guidance,

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a burr was used to correct cam and pincer morphologies.42 Iliopsoas fractional lengthening’s

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were conducted on patients who reported painful internal snapping.43 Fraying or tearing of the

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ligamentum teres was treated by debridement.44 Following the arthroscopic surgery, capsular

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closure was performed, according to a previously published technique, in all patients except

161

those with excessive stiffness, adhesive capsulitis, or insufficient capsular tissue.45–47

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Symptomatic gluteus medius tear were addressed endoscopically according to the Lall et al

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classification system.48 Traction and operative time were also documented for all patients as

164

well.

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Decision making for repairing or reconstructing the labrum was made intraoperatively by

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the senior author (B.G.D).The full algorithm for labral treatment was previously published.49 In

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summary, patients underwent a circumferential reconstruction – from the anterior to posterior

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point of the acetabular transverse ligament (4 O’clock to 7 O’clock in a right hip) - if the labral

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tissue was determined to be irreparable or nonviable. Labral tears were considered irreparable if

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the labrum appeared 1) to be mostly or completely calcified, 2) to be inadequate (nonviable) and

171

not amenable for labral repair.14,23,50 Otherwise, a labral repair was performed.4,51–53 All of the

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potential options for labral treatment such as repair, reconstruction, augmentation and selective

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debridement were discussed with the patient and were a part of the patient’s consent. A 6.5-7.5

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mm single strand tibialis anterior allograft was the graft of choice to limit donor site morbidity.51

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Reconstructions were performed using the knotless pull-through technique, Figure 4.11 This

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procedure involves first removing the entirety of the labrum and then preparing the allograft in a

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single-strand fashion. A specific advantage of this technique is that it does not require

178

measurement of the size of the labral defect. This allows surgeons to obtain a perfect match

179

between the graft and defect every single time. In others words, the graft “mismatch” error is

180

taken out of the equation. Details of the technique were also published in a previous study.11

181 182 183

Labral Repair Technique All repairs were conducted through either a base refixation technique or a controlled-

184

tension anatomic loop stitch.53–55 Sutures were passed through the labrum and then anchored to

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the acetabular rim.56 Following all intra-articular procedures, the hip was removed from traction

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and restoration of the seal between the labrum and the femoral head was confirmed for all

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cases.4,57,58

188 189 190

Postoperative Rehabilitation For six weeks following surgery, all reconstruction patients were restricted to 20 lb.

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weight-bearing and wore a stable DonJoy hip brace (DJO Global, Vista, CA) limiting range of

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motion to 0°-90°. To ensure proper healing, physical therapy was also postponed for six weeks,

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although stationary bike was encouraged from postoperative day one.14 Patients in the repair

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group were instructed to use the brace and crutches for two weeks after surgery and started

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physical therapy on the day following surgery.14 However, adjustments to the protocol were

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made for patients who underwent a microfracture.59 These patients were 20 lb. weight-bearing

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for eight weeks and delayed physical therapy for six weeks. To recover full range of motion,

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continuous passive motion was used on all included patients on the day following surgery.

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Patients were also seen for postoperative appointments with radiographic evaluation at

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the two-week, three-month, and annual time points. Any postoperative complications and

201

reoperations were noted during these visits.

202 203 204

Patient-Reported Outcomes To establish baseline scores, all included patients completed questionnaires within a

205

month of their surgery date that reported mHHS, NAHS, HOS-SSS, iHOT-12, SF-12 M, SF-12

206

P, VR-12M, VR-12 P, and VAS. Following surgery, all patients finished the same questionnaire

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but also reported their satisfaction with surgery and if they underwent additional ipsilateral hip

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surgery. At three-months and then annually, outcomes were recorded at clinical visits, through

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encrypted email, or telephone interviews

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The frequency of patients achieving the minimal clinically important difference (MCID)

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and patient acceptable symptomatic state (PASS) was calculated for the mHHS and iHOT-12

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scores. The MCID values for the mHHS and iHOT-12 scores were eight and 13 respectively, and

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the PASS thresholds were 74 and 63 respectively.60–62

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Rates of secondary surgeries such as a revision arthroscopy or conversion to THA were

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calculated for both groups. Patients were considered for a revision hip arthroscopy if they had

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continued pain, reinjured their hip, were radiographically and clinically evaluated, and had failed

217

conservative treatment. Any patients who had progressed towards osteoarthritis and had

218

unresolved symptoms were recommended for a THA. Postoperative scores for patients who

219

underwent a secondary surgery were excluded from the PROs analysis and reviewed separately.

220 221

Statistical Analysis

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Statistical analyses other than propensity score matching were conducted using Microsoft

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Excel (Microsoft Corp, Redmond, Washington) along with the Real Statistics resource pack.

224

Continuous data were assessed for equal variance and normality using the F test and Shapiro-

225

Wilk test respectively. A student’s t-test or a nonparametric equivalent such as the Mann-

226

Whitney test or a Welch test was then used to analyze the data. Regarding categorical data, a

227

Chi-squared or Fisher’s exact test was used. An a priori power analysis indicated that for a

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power of 0.80, and alpha of 0.05, and a standard deviation of 15, 25 patients were required for

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the circumferential group, and 75 patients were needed in the labral repair control group to detect

230

a ten-point difference in mHHS.63 95% confidence intervals were included for all continuous

231

variables, and a P-value of < 0.05 was set as the threshold for significance.

232 233

Results

234 235

Primary Circumferential Labral Reconstruction Patient Demographics

236

During the study period, 37 hips (37 patients) underwent a circumferential labral

237

reconstruction. Of the 37, two patients underwent contralateral labral repair and are included in

238

the matched-pair analysis. There were 19 (51.4%) females and 18 (48.6%) males, mean age was

239

45.6 ± 11.6 years, average BMI was 27.1 ± 5 kg/m2 for the reconstruction group (Table 1).

240

Average lateral center edge angle and anterior center edge angle were 32.9 ± 7.0 and 31.7 ± 9.0

241

respectively (Table 2). Complete preoperative radiographic measurements and physical exam findings are

242

shown in Table 2.

243

244

Primary Circumferential Labral Reconstruction Intraoperative Findings and

245

Procedures

246

Intraoperative findings and surgical procedures are summarized in Tables 3 and 4

247

respectively. There were 8 (21.6%) Seldes type II labral tears and 29 (78.4%) Seldes combined I-

248

II labral tear. There were 30 patients (81%) with ALAD cartilage damage of grade ≥2, patients

249

30 (81%) with acetabular Outerbridge defects of grade ≥2.

250 251

A capsular repair was performed in 16 patients (43.2%). All the patients underwent femoroplasty and acetabuloplasty.

252 253

Primary Circumferential Labral Reconstruction Patient-Reported Outcomes

254

At minimum two-year follow-up, the primary circumferential labral reconstruction group

255

demonstrated significant improvements in all PROs relative to preoperative baseline scores (P <

256

0001) aside from SF-12 M (P = 0.053), Table 5. Additionally, patient satisfaction was 8.1 ± 2.4.

257

Regarding MCID and PASS, for mHHS 77.1% and 80% of the patients achieved MCID and

258

PASS respectively, and for iHOT-12 79.4% and 71.4% achieved MCID and PASS respectively,

259

Table 6.

260 261

Primary Circumferential Labral Reconstruction Secondary Surgeries and

262

Conversion to Total Hip Arthroplasty

263 264

The frequency of and duration to secondary surgeries in this cohort is displayed in Table 7. No patient underwent secondary arthroscopic surgery, 2 patients (5.4%) converted to THA.

265 266

Nested Matched-Pair Comparison

267 268 269

Patient Demographics After Propensity Matching All 37 patients in the primary circumferential group were successfully matched based on

270

age, gender, and BMI to 111 hips (107 patients) in the primary labral repair control group from

271

the same time frame, Figure 5. Propensity matching achieved a benchmark control group with

272

comparable age (P = 0.318), gender (P = 0.991), and BMI composition (P = 0.821), Table 1. The

273

circumferential group had a slightly shorter follow-up time compared to the labral repair control

274

group (25.5 ± 1.6 vs 27.3 ± 3.5 months, P = 0.004), Table 1. Additionally, the circumferential

275

group had a higher average LCEA relative to the labral repair control group (32.9° ± 7.0 vs 30.0°

276

± 5.7, P = 0.005), Table 2. Regarding preoperative physical exam measurements, the two groups

277

were similar in terms of flexion and internal rotation. However, the circumferential group had a

278

slightly lower average external rotation (33.1 ± 10.2 vs 40.5 ± 16.2, P < 0.016), Table 2.

279 280 281

Intraoperative Findings and Procedures After Propensity Matching For intraoperative findings, the only significant difference between the circumferential

282

reconstruction and control repair groups was the distribution of Seldes type tears (P = 0.002),

283

Table 3. Regarding surgical procedures, the labral repair group had a significantly higher rate of

284

capsule repair (P < 0.008). No other significant differences were found between the two groups

285

in terms of surgical procedures (Table 4). Lastly, the circumferential group had significantly

286

higher traction and operative times (94.4 ± 22.0 vs 60.2 ± 16.4 and 132.1 ± 20.3 vs 95.1 ± 18.5,

287

respectively).

288 289

Patient-Reported Outcomes After Propensity Matching

290

Between groups, no differences were found in PROs at baseline. At minimum two-year

291

follow-up, both groups demonstrated comparable improvements for mHHS, NAHS, HOS-SSS,

292

iHOT-12, VAS, SF-12 P, SF-12 M, VR-12 M, VR-12 P and patient satisfaction (Table 5, Figure

293

6, and Figure 7). Regarding rates of reaching PASS, there were no significant differences

294

between the two groups (Table 6 and Figure 8).

295 296

Secondary Surgeries and Conversion to Total Hip Arthroplasty After Propensity

297

Matching

298

Rates of revision arthroscopy and conversion to THA for both groups are summarized in

299

Table 7. There were no significant differences between the two groups regarding overall rates of

300

secondary surgery (P = 0.572) or conversion to THA (P = 0.823). All four patients in the repair

301

group who required a secondary hip preservation procedure had a revision arthroscopy for a

302

recurrent labral tear and subsequently underwent a labral reconstruction.

303 304 305

Discussion This study confirmed the author’s hypothesis. In the setting of FAIS and irreparable

306

labral tears, arthroscopic primary circumferential acetabular labral reconstruction using anterior

307

tibialis allograft and the knotless pull-through technique results in (1) significant improvement of

308

PROs and high patient satisfaction at minimum two-year follow-up, and (2) these results were

309

comparable to a matched control primary labral repair group with similar baseline scores.

310

Costa Rocha et al. published one of the first case-series on circumferential labral

311

reconstruction.64 The study included 4 patients (4 hips, 3 females) with the main indication for

312

reconstruction being a calcified labrum which had previously been resected. All patients had

313

acetabular over-coverage [mean LCEA of 50º (range: 39º - 59º)], and all reconstructions were

314

performed using open hip surgical dislocation and a fresh frozen semitendinosus allograft. The

315

authors reported improvement in PROs at latest follow-up [mean of 19 months (range: 6-30

316

months)] and concluded that circumferential labral reconstruction may contribute to the

317

restoration of hip biomechanics. The main difference between this case series and the present

318

study is the open versus arthroscopic approaches used. Since the literature has shown that most

319

FAIS cases that involve pincer-type impingement, with or without over-coverage, can be

320

addressed in a reproducible manner using an arthroscopy , the treatment method of choice is

321

arthroscopic management.65–67 Additionally, in the present study, the reconstruction group’s

322

mean LCEA was 32.9º ± 7.0º. Therefore, this demonstrates that the need for labral reconstruction

323

can occur in patients with “normal” acetabular coverage.68 Lastly, although we agree that labral

324

calcification is one of the most common indications for labral reconstruction regardless of

325

whether it is in the primary or revision setting, it is important to note that this study solely

326

includes patients who underwent primary circumferential labral reconstruction.49,69,70

327

Previously, White et al. also published a case-series reporting on minimum two-year

328

outcomes of circumferential labral reconstruction using iliotibial band allograft tissue.71 The

329

indications for reconstruction were labral size > 8 mm or < 2 mm or an irreparable tear. Overall,

330

their cohort included 123 patients (131 hips) with 69 females (72 hips). Additionally, their study

331

reported on both primary (99 patients) and revision (32 patients) cases. At latest follow-up, 107

332

patients did not require a revision procedure, and for these patients, the authors reported

333

significant improvement in several PROs and concluded that promising outcomes can be

334

obtained with this technique.12 The present study found similar postoperative results for the

335

reconstruction group of the present study (mHHS, P = 0.001; NAHS, P = 0.001; HOS-SSS, P =

336

0.001; VAS, P = 0.001). However, a major limitation of the White et al. study, as the authors

337

appropriately presented, was the lack of control group. In contrast, the current study includes a

338

matched control labral repair group that provides a benchmark for comparison. Based on our

339

findings, in the setting of primary hip arthroscopy and irreparable labral tears, surgeons and

340

patients may expect statistically significant improvements in PROs between circumferential

341

labral reconstruction and a matched-pair control labral repair group in the short-term.

342

Scanaliato et al. also recently compared outcomes of patients who underwent primary

343

circumferential reconstruction with iliotibial band allograft to patients who underwent primary

344

labral repair.72 After the exclusion of failed cases and propensity score matching, 48 primary

345

reconstructions and 80 primary repairs were included for PRO analysis (mHHS, iHOT-12, SF-12

346

M, and SF-12 P). With a mean follow-up of 24 months (SD = 1.9 months) all patients

347

demonstrated statistically significant improvements between pre and postoperative PROs (P <

348

0.01). Additionally, PROs at latest follow-up were comparable between the two groups, and the

349

authors concluded that primary circumferential labral reconstruction results in promising short-

350

term outcomes and is a viable treatment alternative for hips with moderate to severe labral

351

damage. Although the present study found similar results regarding PROS, we performed

352

propensity score matching without excluding patients who had failed treatment. Thus, we were

353

allowed to compare rates of secondary operations between the two matched groups rather than

354

the overall unmatched groups. In addition, even though the current series did not match on

355

baseline PROs, there were no significant differences between the two groups in this regard.

356

Another difference is that this study assessed clinical parameters in addition to statistical

357

significance.63

358

Despite these promising results, when confronting irreparable labral tears, circumferential

359

reconstruction may not be the only suitable option. Segmental labral reconstruction and labral

360

augmentation have also been previously reported on and are valid options as well.7,8,73–75

361

Recently, Chandrasekaran et al. compared 34 hips undergoing primary segmental labral

362

reconstruction to a matched control of 68 primary labral repair hips based on age, gender, BMI,

363

capsular treatment, and chondral damage.23 At minimum two-year follow-up, the authors

364

reported significant improvements in PROs and high patient satisfaction that were similar

365

between the two groups. Additionally, the incidence of secondary procedures was also

366

comparable. Currently, there is a paucity in the literature comparing the outcomes of the

367

segmental and circumferential techniques for labral reconstruction. Thus, further research is

368

necessary to determine which may be superior. Presently, only segmental reconstruction has

369

demonstrated favorable results in the mid-term.13,14,69,76

370

Regarding labral augmentation, Philippon et al. published their results comparing 33 hips

371

undergoing labral augmentations to a matched group of 66 hips receiving segmental labral

372

reconstructions.77 The authors found that the augmentation group had a significantly higher rate

373

of reaching MCID for HOS-Activity of Daily Living (P = 0.002) and HOS-SSS (P = 0.008).

374

However, since the number of studies reporting on labral augmentation is currently limited, more

375

research is required to externally validate these findings.

376

Although this study found favorable outcomes for circumferential labral reconstruction,

377

the results of the current study must be taken with caution. In the presence of viable labra, the

378

authors still consider labral repair as the gold standard treatment due to long-term data

379

supporting its use.1,2 Previously, White et al. proposed systematic primary labral reconstruction

380

over repair. 78 However, with the current data available, this approach cannot be supported.1,14

381

Another factor to consider treating irreparable labral tears is the advanced techniques associated

382

with labral restoration (segmental/circumferential reconstruction and augmentation). Currently,

383

these are among the most demanding procedures in hip arthroscopy, and the steep learning curve

384

may play a critical role in not only favorable results but also low complication rates.6,69,79,80

385 386

Strengths

387

The present study has several noteworthy strengths. First, this is one of the few studies to

388

report PROs following arthroscopic circumferential labral reconstruction, and it is one of the few

389

to specifically use the knotless pull-through technique with allograft. Second, outcomes were

390

assessed using multiple validated functional hip outcome scores in addition to VAS for pain and

391

patient satisfaction. Third, in an effort to control for confounding variables, primary

392

circumferential labral reconstruction patients were propensity score matched to a primary labral

393

repair group for age, gender, and BMI. Confounding effects of hip dysplasia was also eliminated

394

by excluding all patients with a LCEA ≤ 18°. Last, statistical significance does not equate to

395

clinical significance. Thus, this study also reported on the proportion of patients who achieved

396

the MCID and PASS for not only mHHS but also for iHOT-12.63,81

397 398 399

Limitations Limitations of the current study must be recognized. Although this study includes a

400

matched control group, it was conducted in a non-randomized fashion. Consequently,

401

confounding variables may have influenced the results. Second, this study is retrospective in

402

nature which introduces bias; however, prospective data collection was used to limit this bias.

403

Third, the analysis was based on a single institution with a single high-volume hip arthroscopy

404

surgeon who specializes in labral reconstruction surgery, which may limit the generalizability of

405

the results.69,79 Fourth, generalized ligamentous laxity was not considered in this analysis, and

406

with the significant differences found between groups in regard to capsular management this

407

may be a confounding effect.82–85 Fifth, the present study includes short-term outcomes and

408

longer follow-up is mandatory to determine the durability of the results. Sixth, the decision

409

between labral reconstruction and labral repair was based on the senior author’s (B.G.D)

410

expertise and experience, which may also introduce bias.49 Seventh, since revision surgeries and

411

conversion to THA were considered an endpoint outcome, postoperative scores for these patients

412

were not incorporated into the PROs analysis. Eight, although slight the circumferential

413

reconstruction group had a shorter follow-up time compared to the control group. Ninth, as a

414

non-clinically significant limitation, the LCEA was higher in the labral reconstruction group.

415

calcification of the labrum may explain this finding.69 Furthermore, capsular management has

416

evolved and improved, particularly with new data in this regard.83 Consequently, while the study

417

group contains patients who underwent capsulotomy without repair, in the present time, patients

418

with the same surgical indications would be treated with capsular repair. Finally, although an a

419

priori power analysis was performed and fulfilled, the total number of patients in the

420

reconstruction group is relatively small, and further research including a larger case-series is

421

required to validate the results.

422 423

Conclusions

424

Following primary hip arthroscopy, primary circumferential labral reconstruction

425

utilizing anterior tibialis allograft and the knotless pull-through technique in the setting of FAIS

426

and irreparable labral tears resulted in significant improvement in several PROs at minimum

427

two-year follow-up and patient satisfaction. Primary circumferential labral reconstruction

428

reached comparable functional outcomes when compared to a benchmark matched-pair primary

429

labral repair control group.

430 431

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73. Chandrasekaran S, Darwish N, Close MR, Lodhia P, Suarez-Ahedo C, Domb BG. Arthroscopic Reconstruction of Segmental Defects of the Hip Labrum: Results in 22

664 665

Patients With Mean 2-Year Follow-Up. Arthroscopy. 2017;33(9):1685-1693. doi:10.1016/j.arthro.2017.03.015

666 667 668

74. Redmond JM, Cregar WM, Martin TJ, Vemula SP, Gupta A, Domb BG. Arthroscopic Labral Reconstruction of the Hip Using Semitendinosus Allograft. Arthrosc Tech. 2015;4(4):e323329. doi:10.1016/j.eats.2015.03.002

669 670 671

75. Krych AJ. Editorial Commentary: Meet Your Newest Tool in the Hip Labral Preservation Toolbox: Labral Augmentation. Arthroscopy. 2018;34(9):2612-2613. doi:10.1016/j.arthro.2018.07.001

672 673 674

76. Geyer MR, Philippon MJ, Fagrelius TS, Briggs KK. Acetabular labral reconstruction with an iliotibial band autograft: outcome and survivorship analysis at minimum 3-year follow-up. Am J Sports Med. 2013;41(8):1750-1756. doi:10.1177/0363546513487311

675 676 677

77. Philippon MJ, Bolia IK, Locks R, Briggs KK. Labral Preservation: Outcomes Following Labrum Augmentation Versus Labrum Reconstruction. Arthroscopy. 2018;34(9):2604-2611. doi:10.1016/j.arthro.2018.04.021

678 679 680

78. White BJ, Patterson J, Herzog MM. Bilateral Hip Arthroscopy: Direct Comparison of Primary Acetabular Labral Repair and Primary Acetabular Labral Reconstruction. Arthroscopy. 2018;34(2):433-440. doi:10.1016/j.arthro.2017.08.240

681 682 683

79. Mehta N, Chamberlin P, Marx RG, et al. Defining the Learning Curve for Hip Arthroscopy: A Threshold Analysis of the Volume-Outcomes Relationship. Am J Sports Med. 2018;46(6):1284-1293. doi:10.1177/0363546517749219

684 685 686

80. Brand JC, Rossi MJ, Lubowitz JH. Hip Arthroscopy Complications Are Rare, but There Is Room for Improvement. Arthroscopy. 2019;35(5):1297-1299. doi:10.1016/j.arthro.2019.03.009

687 688 689

81. Harris JD, Brand JC, Cote MP, Dhawan A. Research Pearls: The Significance of Statistics and Perils of Pooling. Part 3: Pearls and Pitfalls of Meta-analyses and Systematic Reviews. Arthroscopy. 2017;33(8):1594-1602. doi:10.1016/j.arthro.2017.01.055

690 691 692 693 694

82. Saadat AA, Lall AC, Battaglia MR, Mohr MR, Maldonado DR, Domb BG. Prevalence of Generalized Ligamentous Laxity in Patients Undergoing Hip Arthroscopy: A Prospective Study of Patients’ Clinical Presentation, Physical Examination, Intraoperative Findings, and Surgical Procedures. Am J Sports Med. 2019;47(4):885-893. doi:10.1177/0363546518825246

695 696 697 698

83. Ortiz-Declet V, Mu B, Chen AW, et al. Should the Capsule Be Repaired or Plicated After Hip Arthroscopy for Labral Tears Associated With Femoroacetabular Impingement or Instability? A Systematic Review. Arthroscopy. 2018;34(1):303-318. doi:10.1016/j.arthro.2017.06.030

699 700

84. Han S, Alexander JW, Thomas VS, et al. Does Capsular Laxity Lead to Microinstability of the Native Hip? Am J Sports Med. 2018;46(6):1315-1323. doi:10.1177/0363546518755717

701 702

85. Safran MR. Microinstability of the Hip-Gaining Acceptance. J Am Acad Orthop Surg. 2019;27(1):12-22. doi:10.5435/JAAOS-D-17-00664

703 704 705

Figure Legend and Tables

706 707

Fig 1. Image corresponds to a right hip of a 35 year-old female patient in the supine position.

708

View is from the anterolateral portal with the 70° arthroscope. An irreparable/nonviable labrum

709

(L) is noted during diagnostic arthroscopy, the 3 O’clock is marked (*); A, acetabulum; F,

710

femoral head.

711 712 713

Fig 2. Image corresponds to the right hip of a 35 year-old female patient in the supine position.

714

View is from the anterolateral portal with the 70° arthroscope. A. Circumferential labral

715

reconstruction (R) using tibialis anterior allograft has been performed, the 12 O’clock is marked

716

(*). B. Posterior end of R, the 9 O’clock is marked (*). C. Hip traction has been released and

717

restoration of labral seal is noted, the 12 O’clock is marked (*).Before and After Circumferential

718

Labral Reconstruction Intraoperative Pictures.

719 720 721

Fig. 3. Illustration of a right hip (RH) showing a completed circumferential labral reconstruction

722

(R) using the pull-through technique with a total of 10 knotless suture-anchors (black arrow).

723

Acetabulum (A); 3 O’clock position (*); 12 O’clock position (ƾ); 9 O’clock position (•);

724

Transverse acetabular ligament (TAL).

725 726 727

Fig 4. The Pull-Trough Technique. A. After circumferential placement of the suture-anchors, the

728

allograft (*) is pull from the mid-anterior portal (black arrow) and advanced through the joint. B.

729

Finally allograft (*) is retrieved in the posterolateral portal prior to initiate fixation from medial

730

to lateral.

731 732 733

Fig 5. Flowchart Summarizing the Patient Selection Process.

734 735 736

Fig 6. Preoperative and Postoperative Patient-Reported Outcomes for the Reconstruction and

737

Repair Groups

738 739

Scores are reported as means. mHHS, modified Harris Hip Score; NAHS, Non-arthritic Hip

740

Score; HOS-SSS, Hip Outcome Score – Sports Subscale; iHOT-12, International Hip Outcome

741

Tool–12; SF-12 M, 12-Item Short Form Health Survey Mental; SF-12 P, 12-Item Short Form

742

Health Survey Physical; VR-12 M, Veterans RAND 12-Item Health Survey Mental scores; VR-

743

12 P, Veterans RAND 12-Item Health Survey Physical

744 745

746

Fig 7. Preoperative and Postoperative Visual Analogue Scale and Patient Satisfaction Scores

747 748

Scores are reported as means. VAS, visual analogue scale.

749 750 751

Fig 8. Rates of Meeting Minimal Clinically Importance Difference and Patient Acceptable

752

Symptomatic State

753 754

MCID, minimal clinically importance difference; PASS patient acceptable symptomatic state;

755

mHHS, modified Harris Hip Score; HOS-SSS, Hip Outcome Score – Sports Subscale; iHOT-12,

756

International Hip Outcome Tool.

757 758 759

Table 1. Group Patient Demographics at the Time of Surgery Demographics Hips included in study Left Right Gender Female Male Age at surgery (years, mean, SD, CI)

Reconstruction

Repair

P-value >0.999

17 (45.9%) 20 (54.1%)

53 (47.7%) 58 (52.3%) 0.317

19 (51.4%) 18 (48.6%) 45.6 ± 9.8 [47.9, 42.4]

65 (60.7%) 42 (39.3%) 45.6 ± 11.6 [43.5, 47.9]

0.991

BMI (kg/m , mean, SD, CI)

27.2 ± 4.6 [28.1, 25.7]

27.1 ± 5 [26.2, 28.1]

0.821

Lateral CEA (degrees, mean, SD, CI) Anterior CEA (degrees, mean, SD, CI) Alpha Angle (degrees, mean, SD, CI) Tönnis Angle (degrees, mean, SD, CI) Follow-up time (months, mean, SD, CI)

32.9 ± 7.0 [31.1, 30.5] 31.7 ± 9.0 [31.4, 28.6] 59.7 ± 13.8 [59.8, 55] 4.9 ± 4.3 [6.28, 3.51] 25.5 ± 1.6 [28.1, 24.9]

30.0 ± 5.7 [28.9, 31.1] 30.2 ± 6.5 [28.9, 31.4] 57.8 ± 10.2 [55.8, 59.8] 5.5 ± 4.2 [4.69, 6.28] 27.3 ± 3.5 [26.7, 28.1]

0.005 0.362 0.685 0.362 0.004

2

760

Bold, statistically significant (P < 0.05); SD, standard deviation; CI, confidence interval; BMI,

761

body mass index.

762 763

Table 2. Preoperative Radiographic Measurements and Physical Exam Findings Demographics Lateral CEA (degrees, mean, SD, CI) Anterior CEA (degrees, mean, SD, CI) Alpha Angle (degrees, mean, SD, CI) Tönnis Angle (degrees, mean, SD, CI) Flexion (degrees, mean, SD, CI) Internal Rotation (degrees, mean, SD, CI) External Rotation (degrees, mean, SD, CI)

Reconstruction

Repair

P-value

32.9 ± 7.0 [31.1, 30.5] 31.7 ± 9.0 [31.4, 28.6] 59.7 ± 13.8 [59.8, 55] 4.9 ± 4.3 [6.28, 3.51] 113.5 ± 13.2 [109.0, 118.0] 14.3 ± 9.7 [11.1, 17.6] 33.1 ± 10.2 [29.8, 36.5]

30.0 ± 5.7 [28.9, 31.1] 30.2 ± 6.5 [28.9, 31.4] 57.8 ± 10.2 [55.8, 59.8] 5.5 ± 4.2 [4.69, 6.28] 117.7 ± 8.4 [116.0, 119.0] 17.6 ± 11.3 [15.5, 19.7] 40.5 ± 16.2 [37.5, 43.5]

0.005 0.362 0.685 0.362 0.248 0.103 0.016

764

Bold, statistically significant (P < 0.05); SD, standard deviation; CI, confidence interval; CEA,

765

center-edge angle.

766

Table 3. Intraoperative Findings Noted for Each Group After Matching Process Intraoperative Findings Seldes I II I & II ALAD 0 1 2 3 4 Outerbridge (Acetabulum) 0 1 2 3 4 Outerbridge (Femoral Head) 0 1

Reconstruction, n (%)

Repair, n (%)

0 (0.0%) 8 (21.6%) 29 (78.4%)

29 (26.1%) 13 (11.7%) 69 (62.2%)

P-value 0.002

0.413 1 (2.7%) 6 (16.2%) 16 (43.2%) 11 (29.7%) 3 (8.1%)

4 (3.6%) 36 (32.4%) 37 (33.3%) 28 (25.2%) 6 (5.4%) 0.243

1 (2.7%) 6 (16.2%) 13 (35.1%) 7 (18.9%) 10 (27.0%)

4 (3.6%) 35 (31.5%) 37 (33.3%) 20 (18.0%) 15 (13.5%)

33 (89.2%) 0 (0.0%)

98 (88.3%) 0 (0.0%)

0.558

2 3 4 LT Percentile Class (Domb) 0 – 0% 1 – 0 - <50% 2 – 50 - <100% 3 – 100% LT Villar Class 0 – No Tear 1 – Complete Tear 2 – Partial Tear 3 – Degenerative Tear

767

0 (0.0%) 3 (8.1%) 1 (2.7%)

4 (3.6%) 5 (4.5%) 4 (3.6%) 0.457

22 (59.5%) 6 (16.2%) 8 (21.6%) 1 (2.7%)

59 (53.2%) 27 (24.3%) 17 (15.3%) 8 (7.2%)

21 (56.8%) 0 (0.0%) 8 (21.6%) 8 (21.6%)

59 (53.2%) 9 (8.1%) 23 (20.7%) 20 (18.0%)

0.352

ALAD, acetabular labral articular disruption; LT, ligamentum teres.

768 769 770

Table 4. Surgical Procedures and Operative Time Based on Group After Matching Process Surgical Procedures Capsular Treatment Repair Capsulotomy without repair Acetabuloplasty Femoroplasty Acetabular Microfracture Femoral Head Microfracture Trochanteric Bursectomy Gluteus Medius Repair Suture Staple Transtendinous Double Row Traction Time (minutes, mean, SD, CI) Operative Time (minutes, mean, SD, CI)

771 772

Reconstruction, n (%)

Repair, n (%)

16 (43.2%) 21 (56.8%) 37 (100.0%) 37 (100.0%) 8 (21.6%) 0 (.0%) 13 (35.1%) 5 (13.5%) 2 (40.0%) 3 (60.0%) 0 (0.0%)

77 (69.4%) 34 (30.6%) 102 (91.9%) 111 (100%) 12 (10.8%) 3 (2.7%) 38 (34.2%) 26 (23.4%) 17 (65.4%) 8 (30.8%) 1 (3.8%)

94.4 ± 22.0 [87.1, 102.0]

60.2 ± 16.4 [57.1, 63.3]

132.1 ± 20.6 [125.0, 139.1]

95.1 ± 18.5 [91.6, 98.6]

Bold, statistically significant (P < 0.05); CI, confidence interval.

P-value 0.008

0.164 >0.999 0.165 0.736 >0.999 0.293

<0.001 <0.001

773

Table 5. Groups Preoperative and Postoperative Patient-Reported Outcomes After Matching

774

Process Outcomes mHHS (mean, SD, CI) Pre Latest Pre-Post P-Value Delta NAHS (mean, SD, CI) Pre Latest Pre-Post P-Value Delta HOS-SSS (mean, SD, CI) Pre Latest Pre-Post P-Value Delta VAS (mean, SD, CI) Pre Latest Pre-Post P-Value Delta iHOT-12 (mean, SD, CI) Pre Latest Pre-Post P-Value Delta SF-12 P (mean, SD, CI) Pre Latest Pre-Post P-Value Delta SF-12 M (mean, SD, CI) Pre Latest Pre-Post P-Value Delta

Reconstruction

Repair

P-value

62.9 ± 15.1 [62.9, 57.9] 86.7 ± 18.4 [89.4, 80.4] <0.0001 23.1 ± 16.4 [29.1, 17.5]

60 ± 15.2 [57.2, 62.9] 86.3 ± 15.7 [83.3, 89.4] <0.0001 25.5 ± 18.5 [21.9, 29.1]

0.319 0.396

60.5 ± 16.3 [63.9, 55.1] 86.2 ± 18.6 [88.6, 79.8] <0.0001 24.2 ± 15.4 [27.9, 19]

60.4 ± 18.2 [57, 63.9] 85.4 ± 16.3 [82.2, 88.6] <0.0001 23.8 ± 20.2 [19.9, 27.9]

0.968 0.372

38.7 ± 25.1 [41.5, 29.4] 78.4 ± 27.9 [80.7, 67.9] <0.0001 37.8 ± 21.1 [41, 29.1]

36.8 ± 23.2 [32.1, 41.5] 74.9 ± 27 [69.1, 80.7] <0.0001 34.5 ± 28.3 [28.1, 41]

0.778 0.409

5.1 ± 2.1 [5.59, 4.41] 2 ± 2.5 [2.66, 1.17] <0.0001 -2.9 ± 2.6 [-2.44, -3.82]

5.1 ± 2.2 [4.76, 5.59] 2.1 ± 2.5 [1.68, 2.66] <0.0001 -2.9 ± 2.7 [-3.53, -2.44]

0.914 0.688

34.9 ± 21.7 [39.2, 27.5] 77 ± 28 [82.6, 67.5] <0.0001 41.3 ± 24.2 [47.6, 32.8]

35 ± 21.6 [31, 39.2] 77.8 ± 24.3 [73.1, 82.6] <0.0001 41.9 ± 28.5 [36.4, 47.6]

0.998 0.648

38.2 ± 8.6 [36.9, 35.2] 48.9 ± 10 [50.7, 45.5] <0.0001 10 ± 8.4 [15.3, 6.98]

35.1 ± 9.1 [33.4, 36.9] 48.7 ± 9.6 [46.8, 50.7] <0.0001 13 ± 11.3 [10.8, 15.3]

0.057 0.738

50.4 ± 10.4 [52.5, 46.8] 54.9 ± 8.6 [55.9, 52] 0.0536 3.6 ± 9.3 [4.69, 0.271]

50.3 ± 11.4 [48.1, 52.5] 54.1 ± 8.8 [52.4, 55.9] 0.0446 2.5 ± 10.5 [0.444, 4.69]

0.503

0.917

0.608

0.984

0.899

0.170 0.809 0.431 0.702

VR-12 M (mean, SD, CI) Pre Latest Pre-Post P-Value Delta VR-12 P (mean, SD, CI) Pre Latest Pre-Post P-Value Delta Patient Satisfaction (mean, SD, CI)

53.4 ± 10.3 [54.5, 49.9] 59.7 ± 9.4 [60.5, 56.5] 0.0041 5.3 ± 8.5 [7.02, 2.25]

52.3 ± 11.4 [50.1, 54.5] 58.7 ± 8.6 [57.1, 60.5] <0.0001 4.9 ± 10.1 [2.94, 7.02]

0.703 0.292

39.6 ± 9.2 [39.2, 36.4] 49.9 ± 10.3 [51.9, 46.4] <0.0001 9.5 ± 8.3 [14.3, 6.51] 8.1 ± 2.4 [8.52, 7.28]

37.2 ± 9.9 [35.3, 39.2] 50 ± 9.2 [48.3, 51.9] <0.0001 12.1 ± 10.8 [9.96, 14.3] 8.0 ± 2.2 [7.62, 8.52]

0.218 0.823

0.900

0.211 0.653

775

Bold, statistically significant (P < 0.05); mHHS, modified Harris Hip Score; NAHS, Non-

776

arthritic Hip Score; HOS-SSS, Hip Outcome Score – Sports Subscale; VAS, visual analogue

777

scale, iHOT-12, International Hip Outcome Tool–12; SF-12 M, 12-Item Short Form Health

778

Survey Mental; SF-12 P, 12-Item Short Form Health Survey Physical; VR-12 M, Veterans

779

RAND 12-Item Health Survey Mental scores; VR-12 P, Veterans RAND 12-Item Health Survey

780

Physical; SD, standard deviation; CI, confidence interval.

781 782 783

Table 6. Rates of Reaching Minimal Clinically Importance Difference and Patient Acceptable

784

Symptomatic State for Both Groups After Matching Process MCID, PASS mHHS MCID 8 PASS 74 iHOT-12 MCID 13 PASS 63

Reconstruction (n, %)

Repair (n, %)

P-value

27 (77.1%) 28 (80%)

87 (83.7%) 86 (82.7%)

0.385 0.719

27 (79.4%) 25 (71.4%)

87 (85.3%) 81 (78.6%)

0.419 0.382

785

MCID, minimal clinically importance difference; PASS patient acceptable symptomatic state;

786

mHHS, modified Harris Hip Score; iHOT-12, International Hip Outcome Tool.

787

788

Table 7. Rates of Secondary Surgeries for Both Groups After Matching Process Secondary Surgeries Secondary arthroscopies (n, %) Time to secondary arthroscopy (months, mean, SD, range) THA (n, %) Time to THA (months, mean, SD, range)

789

Reconstruction 0 (0.0%)

Repair 4 (3.6%) 17.4 ± 8.9 (6.8 – 28.2)

P-value -

2 (5.4%) 16.4 ± 7.5 (11.0 – 21.7)

5 (4.5%) 10.2 ± 3.8 (6.3 – 16.2)

0.823 0.188

SD, standard deviation; THA, total hip arthroplasty.