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72 (); 63-79
doi:
10.1016/j.jor.2025.10.019

Arthroscopic management of labral tears in femoroacetabolar impingement: current concepts

, , , , , ,
a Department of Trauma and Reconstructive Surgery, University Hospital of Halle, Martin-Luther University Halle-Wittenberg, 06097, Halle (Saale), Germany
b Department of Orthopaedic and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), 39100, Bolzano, Italy
c Department of Life Sciences, Health, and Health Professions, Link Campus University, 00165, Rome, Italy
d Residency Program in Orthopaedic and Trauma Surgery, University of Milan, Milan, Italy
e Department of Orthopaedic, Gruppo San Donato, Villa Erbosa Hospital, San Raffaele University, Milan, Italy
f Department of Trauma and Orthopaedic Surgery, Faculty of Medicine and Psychology, University La Sapienza, 00185, Roma, Italy
g School of Pharmacy and Bioengineering, Keele University Faculty of Medicine, Stoke on Trent, ST4 7QB, UK
h Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry, Mile End Hospital, Queen Mary University of London, London, E1 4DG, UK

⁎Corresponding author: Filippo Migliorini. filippo.migliorini@uk-halle.de

Received: , Accepted: ,
The Authors
Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Abstract

Surgical intervention for labral lesions associated with femoroacetabular impingement (FAI) has evolved significantly over the past two decades. The earliest surgical approaches include labral debridement and labral repair. More recently, the concept of labral reconstruction has gained popularity. Despite these advancements, a consensus regarding the optimal surgical approach remains elusive. The present systematic review updates the current evidence on the arthroscopic management of labral ailments in patients with symptomatic FAI.

This systematic review adhered to the PRISMA statement. The Web of Science, PubMed, and Embase databases were accessed in July 2025. All clinical investigations comparing two different labral management methods for FAI were included.

Data from 23,222 patients were retrieved. Of them, 54.6 % (12,683 of 23,222 patients) were women. The mean follow-up duration was 33.0 ± 19.4 months. The mean age was 35.0 ± 6.3 years, and the mean BMI was 25.1 ± 1.3 kg/m2.

The current evidence on arthroscopic management of labral tears in femoroacetabular impingement is limited and heterogeneous. Available data suggest potential advantages of labral preservation and reconstruction over debridement, but these findings cannot be considered definitive. At present, no strong clinical recommendations can be made. Further randomized controlled trials with long-term follow-up are required to clarify the optimal surgical strategy.

Keywords

FAI
Femoroacetabular impingement
Labrum
Labral tears
1

1 Introduction

Femoroacetabular impingement (FAI) is characterised by abnormal contact between the femoral head-neck junction and the acetabular rim arising from anatomical variations.1–6 Initially conceptualised in the late 1990s, FAI has since been recognised as a cause of hip pain and degenerative joint disease, particularly in young, active patients such as athletes.1,7–11 FAI is classified into three distinct types based on the impingement mechanism: cam, pincer, and mixed.12–19 The repetitive mechanical strains and stresses exerted by FAI contribute to articular cartilage damage and substantially increase the risk of labral tears and early osteoarthritis from compromised structural integrity of the hip joint biomechanics.20–24

The acetabular labrum plays a crucial role in maintaining hip stability by deepening the acetabular socket, distributing the load, and preserving the joint's fluid seal and negative pressure.25–27 The integrity of this suction-seal mechanism is essential for minimising microinstability and protecting cartilage by relieving friction forces within the joint. Labral damage, therefore, significantly disrupts this protective mechanism, leading to increased contact stress between the femoral head and the acetabulum.28 These heightened stresses can accelerate cartilage matrix erosion and degeneration, potentially leading to early osteoarthritis.3,4,23,28 While labral tears were once considered uncommon, modern imaging techniques and advances in arthroscopy have made the diagnosis and treatment of labral tears more prevalent.29–31 The prevalence of chondrolabral injury in patients with hip or groin pain ranges from 22 % to 55 %.32–34

Surgical intervention for labral lesions associated with FAI has evolved significantly, resulting in a dramatic increase in the number of procedures over the past two decades.5,35–40 The earliest surgical approaches include labral debridement and repair, which aim to alleviate symptoms and restore joint function.41–43 However, the choice between labral debridement and repair has remained controversial over the last few decades, with conflicting evidence regarding their relative effectiveness in relation to patients' characteristics. Some studies suggest that labral repair offers superior clinical and radiographic outcomes by restoring the essential functions of the labrum. In contrast, others reported comparable or superior short-term outcomes with labral debridement in non-arthritic hips.44–47 More recently, the concept of labral reconstruction has gained popularity, particularly in patients with irreparable labral tissue.48,49 A growing body of literature supports labral reconstruction as an advanced arthroscopic procedure capable of fully restoring intra-articular pressure to levels observed in intact labrums, as demonstrated in cadaveric models.26,50 Various arthroscopic techniques and graft solutions have been developed to address labral damage, depending on the location of the tear and the quality of the labral tissue.50,51 Emerging evidence suggests that labral reconstruction may offer superior long-term joint preservation compared to debridement alone.52

Despite these advancements, a consensus remains elusive regarding the optimal surgical approach for labral tears in FAI, including the role of reconstruction, graft selection, and specific surgical techniques. Given the lack of conclusive evidence and the variability in clinical practice, the present systematic review updates the current evidence on the arthroscopic management of labral ailments in patients with symptomatic FAI.

2

2 Methods

2.1

2.1 Eligibility criteria

All available clinical studies investigating the arthroscopic management of FAI underwent review. Only studies with a minimum of six months of follow-up were considered. Only studies published in peer-reviewed journals were considered eligible. Articles in English, German, Italian, Spanish, or French were included. Only studies classified as levels I to IV evidence, according to the 2020 Oxford Centre of Evidence-Based Medicine,53 were included. Reviews, editorials, letters, and opinions were excluded. Moreover, studies involving animals, in vitro experiments, computational analyses, biomechanical assessments, or cadaveric research were disregarded.

2.2

2.2 Search strategy

The current systematic review adhered to the guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement of 2020.54 The following algorithm was used for the literature search:•Problem: Femoroacetabular impingement•Intervention: arthroscopy•Design: comparative clinical trial.•Comparison: labral procedures (resection, repair, reconstruction)•Timing: minimum of six months of follow-up

In July 2025, the following databases were accessed: PubMed, Web of Science, and Embase, with no additional filters or time constraints. The Medical Subject Headings (MeSH) used for the database search are detailed in the Appendix.

2.3

2.3 Selection and data collection

Two authors (J.E. and T.B.) conducted the database search. All retrieved titles were screened manually, and the abstracts were reviewed if deemed appropriate. Full texts were examined in cases where there was a match. Articles without accessible full texts were excluded from consideration. A cross-reference of the bibliographies of full-text articles was also conducted for potential inclusion. A third senior author (N.M.), who made the final decision, resolved disagreements.

2.4

2.4 Data items

Two authors (J.E. and T.B.) performed data extraction. The following data at baseline were extracted: author, year of publication and journal, length of the follow-up, number of patients with related mean age, and BMI. Data were extracted in Microsoft Office Excel version 16.0 (Microsoft Corporation, Redmond, USA).

2.5

2.5 Assessment of the risk of bias

The guidelines in the Cochrane Handbook for Systematic Reviews of Interventions55 were used to evaluate the risk of bias. Two authors (G.P. and T.B.) independently assessed the risk of bias in the extracted studies. Randomised controlled trials (RCTs) were evaluated using the revised Risk of Bias assessment tool (RoB2)56,57 of the Cochrane tool for assessing the Risk of Bias in randomised trials (RoB).58 The following endpoints were considered: bias arising from the randomisation process, bias due to deviations from intended interventions, bias due to missing outcome data, bias in the measurement of the outcome, and bias in the selection of the reported result.

Nonrandomised controlled trials (non-RCTs) were evaluated using the Risk of Bias in Nonrandomised Studies of Interventions (ROBINS-I) tool.59 Seven domains of potential bias in non-RCTs were assessed. Two domains assess the possible confounding and the nature of patient selection before the start of the comparative intervention. Bias in the classification during the intervention is assessed by a further domain. The final four domains are used to assess the methodological quality after the intervention comparison has been implemented and relate to deviations from previously intended interventions, missing data, erroneous measurement of outcomes, and bias in the selection of reported outcomes. The figure of the ROBINS-I was elaborated using the Robvis Software (Risk-of-bias VISualization, Riskofbias.info, Bristol, UK).60

2.6

2.6 Synthesis method

The main author (F.M.) performed the statistical analyses in accordance with the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions.55 For descriptive statistics, the IBM SPSS software version 25 was used. The arithmetic mean and standard deviation were used for continuous data, while the frequency (events/observations) was used for dichotomous variables.

3

3 Results

3.1

3.1 Study selection

A comprehensive search identified 1245 articles pertinent to the research query. After removing duplicates, 688 articles were assessed for eligibility based on their abstracts. Ultimately, 397 articles were excluded as they failed to meet the predetermined criteria, primarily due to methodological incongruence (N = 243). Language barriers (N = 24) and limitations in full-text accessibility (N = 130) further contributed to article exclusion. A rigorous full-text review of the remaining 291 articles resulted in the exclusion of an additional 167. The specific reasons for exclusion at the full-text stage were as follows: wrong patient population or indication (N = 62), incorrect intervention or comparator (N = 55), outcomes of interest not reported (N = 31), inappropriate study design (e.g., non-comparative studies) (N = 19). This thorough selection process yielded a final selection of 124 studies for this systematic review. The results of the literature search are shown in Fig. 1.

PRISMA flow chart of the literature search.
Fig. 1 PRISMA flow chart of the literature search.
3.2

3.2 Risk of bias assessment

The methodological quality and overall strength of the evidence included in this systematic review are substantially limited by the predominance of non-randomised observational studies, which are inherently exposed to confounding, selection bias, and heterogeneity in both design and reporting. Only one study met the criteria for a Randomised Controlled Trial (RCT), and this was assessed using the Cochrane Risk of Bias 2 (RoB 2) tool. The evaluation indicated a low risk of bias in domains such as randomisation, adherence to intended interventions, completeness of outcome data, and selective reporting. Nonetheless, the absence of blinded outcome assessment introduced a moderate risk of bias in the measurement of results, leading to an overall judgement of moderate risk for this trial (Fig. 2). The presence of a single RCT with these limitations severely constrain the level of evidence and underscores the lack of high-quality data in this field. Consequently, while this trial provides valuable insights, its findings cannot be considered broadly generalisable and should not be interpreted as sufficient to guide definitive clinical recommendations.

The RoB2 of RCTs.
Fig. 2 The RoB2 of RCTs.

The ROBINS-I tool was used to assess the risk of bias in the non-randomised studies included in this review, and the results revealed substantial methodological weaknesses. A serious or moderate risk of bias due to confounding was identified in approximately three-quarters of the studies. This level of confounding fundamentally compromises internal validity, as unmeasured or inadequately controlled variables may plausibly explain the reported outcomes rather than the interventions themselves. Although the risk of bias was generally low in domains such as participant selection and classification of interventions, these strengths are insufficient to counterbalance the critical impact of confounding. Additional concerns were identified with incomplete outcome data, raising the possibility of attrition bias. Collectively, these methodological shortcomings create a pervasive risk of bias across the body of non-randomised evidence, generating both clinical and statistical heterogeneity. As a result, the reliability of pooling these data for any form of quantitative synthesis is severely limited. Any aggregated findings must therefore be regarded with extreme caution, as they remain highly vulnerable to systematic error (Fig. 3).

The ROBINS-I of non-RCTs.
Fig. 3 The ROBINS-I of non-RCTs.
3.3

3.3 Study characteristics and results of individual studies

Data from 23,222 patients were retrieved. Of them, 54.6 % (12,683 of 23,222 patients) were women. The mean follow-up duration was 33.0 ± 19.4 months. The mean age was 35.0 ± 6.3 years, and the mean BMI was 25.1 ± 1.3 kg/m2. Generalities of the included studies are shown in Table 1.

4

4 Discussion

Labral debridement was historically one of the first surgical interventions used to treat labral tears associated with FAI.61 However, debridement has fallen out of favour compared to repair and reconstruction due to its association with inferior long-term outcomes, particularly in younger, active populations.62 Larson et al.63 compared labral debridement and labral repair in 94 hips, and patients who underwent labral repair had significantly better outcomes than the debridement group. Krych et al.62 reinforced these findings in younger athletes, demonstrating a faster return to sport and restoration of pre-injury levels with repair compared to debridement. These studies support the preservation of the labrum in young, active patients, resulting in better functional outcomes and a lower incidence of osteoarthritis progression after repair.62 Hassebrock et al.64 reported higher revision rates after debridement than after repair or reconstruction.

In long-term follow-up, labral repair demonstrated better patient-reported outcomes (PROs) and overall survivorship compared to debridement.65 Short-to mid-term results are more variable. Wirris et al.66 analysed 1639 patients (repair vs. debridement) and found no difference in functional outcomes or conversion rates to total hip arthroplasty (THA). Multivariate analysis identified cartilage damage grade as the only independent predictor of outcomes and THA-free survival.66 Su et al.67 conducted a matched controlled study (repair vs reconstruction; 76 per group) and found no significant differences in functional outcomes or revision rates at two years. Robinson et al.68 observed higher conversion to THA in the debridement group at 6.5 years (not evident at 1.6 years), supporting a longer-term advantage for repair over debridement. Maldonado et al.69 compared labral reconstruction with debridement in 76 patients with irreparable tears (38 per group): reconstruction yielded significantly better functional outcomes, and segmental resection was associated with a fourfold higher likelihood of THA compared with reconstruction.69 White et al.70 reported a higher failure rate after repair than after reconstruction. Scanaliato et al.71 (reconstruction vs repair; n = 130) showed improvement in both groups at five years, with a greater increase in Harris Hip Score in the reconstruction group and no significant differences in revision or THA rates. In patients >40 years, White et al.72 found higher mHHS and lower failure with reconstruction vs repair, with similar THA conversion rates. Bryan et al.73 compared outcomes in patients >55 vs < 55 years: Tönnis scores did not differ; debridement was more common in older patients; no functional differences at one year, while younger patients showed greater improvement at two years. Byrd et al.81 compared adolescents (∼16 years) and young adults (∼36 years): functional improvement was similar, with different recovery trajectories (earlier plateau in young adults; continued gains in adolescents). In patients over 40, no significant differences were found in PROMs and survivorship between repair and reconstruction, supporting reconstruction as a valid option in irreparable tears.84 White et al.72 found no significant difference in THA conversion rates between patients aged 30–39 years and those aged 40 years or older. Maldonado et al.90 compared professional vs amateur tennis players and found no differences in functional improvement or return-to-sport rates. Sheu et al.91 analysed professional (n = 25) vs amateur (n = 60) athletes after labral repair: both improved significantly in PROMs without between-group differences; all professionals returned to their prior level within six months. Jimenez et al.92 compared reconstruction versus repair in elite athletes (17 vs. 35): both groups showed similar improvements, with comparable return-to-play rates and times (82.4 % vs. 82.8 %). Fabricant et al.94 evaluated the physiological version, retroversion, and anteversion: PROMs were similar between the physiological and anteversion groups; retroversion improved, but to a smaller magnitude. A meta-analysis reported that abnormal femoral version does not significantly affect outcomes after hip arthroscopy for labral tears.95 Gürsan et al.97 identified an alpha-angle cutoff of 48.3° at five-year follow-up, below which PASS and mHHS improved significantly. Shao et al.100 reported similar functional scores and low revision/THA rates when comparing focal vs global pincer deformities. Two RCTs showed that, in patients with labral tears and Tönnis <2, hip arthroscopy provides significantly better functional outcomes than physiotherapy alone.101,102 Byrd et al.104 found no significant difference in functional gains between Tönnis 0–1 and Tönnis 2. In a systematic review, Domb et al.105 reported higher progression to THA in OA vs non-OA patients (23 % vs 8.3 %), with a 41 % THA rate in Tönnis 2 vs 11 % in Tönnis 0–1 at two years. Filan et al.106 reported 10-year survivorship and outcomes in advanced OA (Tönnis 2–3) vs matched non-OA: survivorship 57 % vs 87 %, higher in Tönnis 2 (68 %) than Tönnis 3 (25 %); OA patients who avoided THA had PROs comparable to controls.

The current body of evidence supports a progressive shift in the management of labral pathology in symptomatic FAI, moving away from resection techniques towards labral preservation and restoration. Across multiple comparative investigations, repair has demonstrated favourable outcomes over debridement, particularly in younger and more active patients, where functional recovery and joint preservation appear more reliable. Reconstruction has emerged as a valuable strategy in the context of irreparable labral tears, with encouraging mid-term results that suggest its role as a viable alternative when preservation is not feasible. Nevertheless, retrospective cohorts with variable methodology dominate the evidence base; the present synthesis should be viewed as an overview of prevailing trends and evolving strategies rather than as a platform for definitive clinical recommendations. The key current concept is that labral preservation and restoration are preferred whenever possible, reconstruction is gaining ground as a salvage option, and debridement should be reserved for carefully selected cases, always recognising the limitations of the available data.

This review presents several limitations that should be recognised. The current body of literature remains largely observational, with the majority of available studies based on retrospective cohorts or single-centre case series. The lack of high-quality randomised controlled trials considerably weakens the strength of the evidence and exposes the conclusions to potential bias. The studies included in this review exhibit considerable heterogeneity. Surgical strategies differ substantially in terms of portals, fixation methods, suture techniques, and graft selection. Rehabilitation protocols also vary, ranging from early mobilisation to strict and prolonged restrictions, while patient populations are inconsistent with respect to age, activity levels, associated chondral injuries, and femoroacetabular morphology. Such variability complicates direct comparisons and limits the generalisability of the findings. Outcome reporting is equally inconsistent. Although patient-reported outcome measures are commonly described, a wide range of different scores have been used, and in some cases, modified versions of validated tools. Data on complications, revision rates, return to sport, or conversion to hip arthroplasty are often incomplete or confined to the short term, which reduces the reliability of long-term conclusions. Follow-up length is also uneven, with some studies reporting outcomes at less than two years and others extending to more than a decade, preventing a uniform evaluation of durability. Inclusion criteria are rarely consistent, with some studies selecting only young, active individuals, while others report more heterogeneous populations, sometimes including advanced stages of the disease. Methodological shortcomings, such as small sample sizes, lack of blinding, or incomplete baseline reporting, further compromise the internal validity of the available evidence. Taken together, these limitations demonstrate that the available literature offers insights and trends rather than definitive recommendations. For this reason, the conclusions of the present review should be interpreted with caution. Progress in this field will require well-conducted randomised controlled trials, greater standardisation of outcome reporting, and longer follow-up to determine the long-term value of labral repair, reconstruction, and debridement in the setting of FAI.

Future research in this field should overcome the limitations of the current evidence base. Well-designed randomised controlled trials are urgently needed to provide higher-quality data and reduce the risk of bias inherent to observational designs. Standardisation of outcome reporting would allow more meaningful comparisons between studies and facilitate future meta-analyses. Longer follow-up is essential to determine the durability of labral repair and reconstruction and to assess the actual risk of conversion to hip arthroplasty. Advances in imaging, biological augmentation, and refined surgical techniques may also improve the quality of repair and reconstruction; however, these innovations require rigorous evaluation in comparative studies. Collaborative multicenter registries and prospective trials may represent the most effective strategy for generating robust evidence and guiding practice.

5

5 Conclusions

The available evidence on arthroscopic management of labral tears in FAI remains limited and largely observational. Comparative data are scarce, and only one randomised trial has been published to date. Reported outcomes suggest that labral preservation and restoration techniques may be associated with more favourable results compared with debridement, while reconstruction represents a possible option in cases of irreparable lesions. However, these findings must be interpreted with caution, as heterogeneity in study design, patient populations, surgical methods, and outcome measures limits the strength of the conclusions. At present, the literature should be viewed as providing signals and trends rather than definitive recommendations. High-quality randomised controlled trials with standardised outcome reporting and long-term follow-up are needed to establish the true role of labral repair, reconstruction, and debridement in the management of FAI.

Author contribution statement

FM: conception and design, statistical analysis, drafting; NM: supervision, revision; MP, MM: writing; TB: literature search, data extraction, risk of bias assessment; JE: literature search, data extraction; GP: risk of bias assessment. All authors read and approved the final manuscript.

Ethical approval

This study complies with ethical standards.

Registration and protocol

The present study was not registered.

Availability of data and materials

The datasets generated during and/or analysed during the current study are available throughout the manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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