DR M.N.BASU MALLICKA R T H R O S C O P Y A N D S P O R T S S U R G E R Y

A P O L L O G L E N E A G L E S H O S P I T A L , K O L K A T A

Femoro-Acetabular impingement

Does Labrectomy have a role?

Femoro acetabular impingement

Abutment of the femoral head neck junction to the acetabular margin Causes intermittent pain initially, and continuous pain later. Clicking, locking Progresses to permanent damage to the labrum and cartilage, ending in OA hip

Diagnoses by Impingement tests

Xray – Abnormal head neck morphology (alfa angle) Acetabular retroversion (crossover sign) Coxa profunda (medialised teardrop)

Confirmation by MRIKassarjian triad of MR findings Abnormal head and neck morphology Anterosuperior cartilage abnormalities Anterosuperior labral abnormalities.

Patterns

CAM-

Abnormal morphology of femoral head-neck jn - anterior aspect

Young athletic males

Shear injury - cartilage damage > labral damage

PINCER

Acetabular margin projection

Middle aged athletic females

Osteophytes, coxa profunda, retroverted acetabulum

Impaction injury – labral damage prominent

MIXED

Commonest type

SCFE

Neck femur fractures

Perthes disease

Geographical morphology

FAI – pathopysiology of damage

CAM

Shear forces at chondro-labral junction

Labral tears

Chondro-labral separation

Cartilage delamination and peel off

Osteoarthritis

PINCER

Impaction at labral margin

Tears and rip off

Treatment philosophy

Conservative

Restriction of inciting activity

Surgery

To restore normal roll and glide of the joint

Excision of the extra bone from the femoral head neck junction (cam)

Rim trimming of the acetabular margin (pincer)

Labrum is reattached if torn / surgically detached for rim trim

OPEN/ ARTHROSCOPIC/ ARTHROSCOPY+OPEN

The Labrum

Increases containment / inreases stability

Suction socket principle – creates a fluid film that prevents close contact within the joint

EVIDENCE

Routine repair of the labrum resulted in higher clinical scores in studies that compared labralrepair with without labral repair in the management of pincer-type FAI (Espinosa et al./ Larson et al.)

A case for LABRECTOMY

Role of labrum in containment and stability in non dysplastic hips – DOUBTFUL

Suction socket mechanism disrupted with damaged labrum, damaged cartilage, aspherical contour and inflammatory synovial fluid

Restoration of normal biomechanics in a repaired labrum – DOUBTFUL

Healing of labrum of limited vascularity - DOUBTFUL

A case for LABRECTOMY

EVIDENCE

Sustained improvement in clinical scores after isolated labral débridement of various patterns of labraldamage in patients without synovitis or arthritis (Byrd and Jones / Santori and Villar / Farjo et al/ Haviv and

O’Donnell )

In vitro biomechanical data suggest there is nil deleterious effect after the removal or detachment of small amounts of the labrum (Greaves et al/ Smith et al. )

Material And Method

10 hips, 8patients- 6males 2 females / Age 27-48

June 2011- June 2013 / follow up 13m – 36m

Diagnosis Pincer type 3 (osteophyte 3)

Mixed type 7 ( healed AVN 2/ ?healed perthes 1/ Idio 4)

Cam type 1 excluded from this study

Arthroscopic labral excision for pincer/mixed FAI

Cartilage status evaluated by OUTERBRIDGE SCALE

Post op follow up at 1m/2m/6m/6monthly

FU evaluated by Roles-modesly Score / Oxford Hip Score

Hip arthroscopic instrumentation/30 deg 4mm scope

Evaluation criteria

OUTERBRIDGE SCALE

0 – No damage

1- softening

2- Fibrillation /cleavage<1cm

3- Fibrillation /cleavage>1cm

4- eroded cartilage, bone

exposed

Roles–MaudsleyScore

1 = excellent, no pain, full

movement, full activity

2 = good, occasional

discomfort, full movement,

and full activity

3 = fair, some discomfort after

prolonged activity

4 = poor, pain limiting

activities.

Technique

Fem hd

Lab

Aet

Technique

Case 2

Fem hd

L

Case 3

Fem hd

lab

Acet

Case 4

Femhd

L

Acet

Case 5

Results SL NO

DIAG PROCEDURE OUTERBRIDGE

PRE-OP RM/Ox

2M 6M 1YR 2YR 3YR

1 Osteophyte Labrectomy + rim trim 4 4/33 3 2 2/43 2/42

2 Osteophyte Labrectomy + rim trim 2 4/34 3 2 2/43 2/43

3 Osteophyte Labrectomy + rim trim 4 4/37 3 2 2/43

4 AVN Labrectomy + headosteophyte removal

3 4/37 3 2 2/42

4 AVN Labrectomy + headosteophyte removal

3 4/40 3 2 2/44

5 Perthes Labrectomy + headosteophyte removal

4 4/37 3 2 3/40 3/41 3

6 Idiopathic Labrectomy + camremoval

3 4/34 3 2 2/44

7 Idiopathic Labrectomy + camremoval

4 4/38 3 3 3/40 2/42 2

8 Idiopathic Labrectomy + camremoval

4 4/39 3 2 2/45

8 Idiopathic Labrectomy + camremoval

3 4/37 3 2 2/44

Discussion

The benefits of labral ‘repair’ in FAI is not clear and is done almost empirically. On the other hand a residual damaged labrum may continue to alter the hip biomechanics, causing continuing damage to the articular cartilage and early onset OA.

Labrectomy takes away one of the culprits and pain generators in FAI, and may be a better option biomechanically. However ‘labrectomy’ alone is not beneficial in the treatment for FAI and does not relieve pain or impingement in the presence of pathological bone (healed Perthes, AVN).

Labrectomy gives predictable favourable short term benefit in pincer and mixed type FAI

Maximal benefit is achieved in 6 months and is maintained thereafter

Grade 4 Outerbridge damage may not have long lasting benefit.

Limitation of the study

No sportsmen in the group

Labral pathology was not the only pathology that was tackled

All patients had some degree of cartilage damage (outerbridge 3/4

No cohort group of labral repair

Follow up less than 2-3 years. Long term outcome unknown.