Author Reply: Labrum-Preserving Hip Arthroscopy and Bone Marrow Aspirate Injection for Patients With Symptomatic Labral Tears and Early Degenerative Changes

We are thankful for the opportunity to respond to the letter from Dean et al.1Dean M.C. Torabian K.A. LaPorte Z.L. Dowley K.S. Cherian N.J. Martin S.D. Regarding “Hip arthroscopy with bone marrow aspirate injection for patients with symptomatic labral tears and early degenerative changes shows similar improvement compared with patients undergoing hip arthroscopy with symptomatic labral tears without arthritis.”.Arthroscopy. 2023; 39: 1954-1955Scopus (1) Google Scholar regarding our article “Hip Arthroscopy With Bone Marrow Aspirate Injection for Patients With Symptomatic Labral Tears and Early Degenerative Changes Shows Similar Improvement Compared With Patients Undergoing Hip Arthroscopy With Symptomatic Labral Tears Without Arthritis.”2Day M.A. Hancock K.J. Selley R.S. et al.Hip arthroscopy with bone marrow aspirate injection for patients with symptomatic labral tears and early degenerative changes shows similar improvement compared with patients undergoing hip arthroscopy with symptomatic labral tears without arthritis.Arthroscopy. 2023; 39: 1429-1437Abstract Full Text Full Text PDF Scopus (3) Google Scholar We appreciate their interest in our article and would like to address their concerns. In their letter, Dean et al. note that there is heterogeneity in the management of the labrum with 4 different surgeons. Although our study was not a single-surgeon study, all 4 surgeons have undergone similar training and used a largely homogeneous approach to labral management. Furthermore, because the arthritic group had a larger proportion of patients undergoing labral debridement compared with repair, this may represent a worst-case scenario to compare with the control group. However, it must be noted that the study with the longest-term follow-up in the literature comparing debridement with repair did not identify a difference in outcomes.3Menge T.J. Briggs K.K. Dornan G.J. McNamara S.C. Philippon M.J. Survivorship and outcomes 10 years following hip arthroscopy for femoroacetabular impingement: Labral debridement compared with labral repair.J Bone Joint Surg Am. 2017; 99: 997-1004Crossref PubMed Scopus (232) Google Scholar Dean et al. also suggest that an improper comparison was made because the extent of arthritis was not the same in both groups.2Day M.A. Hancock K.J. Selley R.S. et al.Hip arthroscopy with bone marrow aspirate injection for patients with symptomatic labral tears and early degenerative changes shows similar improvement compared with patients undergoing hip arthroscopy with symptomatic labral tears without arthritis.Arthroscopy. 2023; 39: 1429-1437Abstract Full Text Full Text PDF Scopus (3) Google Scholar Although the ideal control group for this study is a patient population with a similar degree of arthritis that did not receive bone marrow aspirate concentrate (BMAC), the inclusion of such a comparator group would be impractical and clinically unsound. It is well established that patients with Tönnis grade 1 to 2 changes have inferior outcomes from hip arthroscopy in the absence of a biological augmentation.3Menge T.J. Briggs K.K. Dornan G.J. McNamara S.C. Philippon M.J. Survivorship and outcomes 10 years following hip arthroscopy for femoroacetabular impingement: Labral debridement compared with labral repair.J Bone Joint Surg Am. 2017; 99: 997-1004Crossref PubMed Scopus (232) Google Scholar,4Nho S.J. Beck E.C. Nwachukwu B.U. et al.Survivorship and outcome of hip arthroscopy for femoroacetabular impingement syndrome performed with modern surgical techniques.Am J Sports Med. 2019; 47: 1662-1669Crossref PubMed Scopus (69) Google Scholar Our results are all the more compelling in that we achieved good outcomes with the addition of BMAC in this group, which is otherwise expected to fare poorly. Another concern was raised regarding the incidence and time to conversion to total hip arthroplasty. We showed that 14.3% of the BMAC group and 2.9% of the control group required conversion to total hip arthroplasty, at a mean of 1.6 years and 7 years, respectively.2Day M.A. Hancock K.J. Selley R.S. et al.Hip arthroscopy with bone marrow aspirate injection for patients with symptomatic labral tears and early degenerative changes shows similar improvement compared with patients undergoing hip arthroscopy with symptomatic labral tears without arthritis.Arthroscopy. 2023; 39: 1429-1437Abstract Full Text Full Text PDF Scopus (3) Google Scholar Our study had lower conversion rates than those previously reported in the literature.5Domb B.G. Chaharbakhshi E.O. Rybalko D. Close M.R. Litrenta J. Perets I. Outcomes of hip arthroscopic surgery in patients with Tönnis grade 1 osteoarthritis at a minimum 5-year follow-up: A matched-pair comparison with a Tönnis grade 0 control group.Am J Sports Med. 2017; 45: 2294-2302Crossref PubMed Scopus (79) Google Scholar, 6Chandrasekaran S. Darwish N. Gui C. Lodhia P. Suarez-Ahedo C. Domb B.G. Outcomes of hip arthroscopy in patients with Tönnis grade-2 osteoarthritis at a mean 2-year follow-up: Evaluation using a matched-pair analysis with Tönnis grade-0 and grade-1 cohorts.J Bone Joint Surg Am. 2016; 98: 973-982Crossref PubMed Scopus (61) Google Scholar, 7Domb B.G. Gui C. Lodhia P. How much arthritis is too much for hip arthroscopy: A systematic review.Arthroscopy. 2015; 31: 520-529Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar However, the small sample size limits the power to detect potentially important differences after hip arthroscopy in the early arthritic and nonarthritic groups. The difference in time to arthroplasty, with conversion occurring earlier in the postoperative course in the arthritic group, suggests that in patients with Tönnis grade 1 to 2 changes, hip arthroscopy with BMAC may be beneficial in the short term. A small proportion of patients required early conversion to total hip arthroplasty (<24 months), whereas the remaining patients showed durable and comparable improvement to patients without arthritis undergoing hip arthroscopy for symptomatic labral tears. In summary, we believe that our results support the hypothesis that in a challenging group of patients with symptomatic labral tears and early radiographic degenerative changes, hip arthroscopy with BMAC injection results in improvements in patient-reported outcomes comparable to a group of patients without arthritis undergoing hip arthroscopy at short-term follow-up.2Day M.A. Hancock K.J. Selley R.S. et al.Hip arthroscopy with bone marrow aspirate injection for patients with symptomatic labral tears and early degenerative changes shows similar improvement compared with patients undergoing hip arthroscopy with symptomatic labral tears without arthritis.Arthroscopy. 2023; 39: 1429-1437Abstract Full Text Full Text PDF Scopus (3) Google Scholar We acknowledge the evolving landscape of biological interventions in orthopaedics, which necessitates a high level of scrutiny of published biological techniques. We believe that our article is an important addition to the biologics evidence base and helps to support a biological approach to hip impingement. The data in this report are suitable as pilot data for further investigation while care is taken to appropriately select and counsel patients. Download .pdf (8.96 MB) Help with pdf files ICMJE author disclosure forms Regarding “Hip Arthroscopy With Bone Marrow Aspirate Injection for Patients With Symptomatic Labral Tears and Early Degenerative Changes Shows Similar Improvement Compared With Patients Undergoing Hip Arthroscopy with Symptomatic Labral Tears Without Arthritis”ArthroscopyVol. 39Issue 9PreviewWith great interest, we recently read the article by Day et al., which investigates the clinical effect of intraarticularly injected, iliac crest-derived bone marrow aspirate concentrate (BMAC) during hip arthroscopy in patients with symptomatic labral tears and early radiographic degenerative changes.1 Although the authors’ findings align with existing outcome studies assessing BMAC augmentation in the setting of hip arthroscopy, we would like to highlight some methodological issues and reporting discrepancies that may warrant clarification. Full-Text PDF