DR M.N.BASU MALLICKARTHROSCOPY AND SPORTS

SURGERYAPOLLO GLENEAGLES HOSPITAL,

KOLKATA

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

CAMShear forces at chondro-labral junctionLabral tearsChondro-labral separationCartilage delamination and peel offOsteoarthritis

PINCERImpaction at labral marginTears and rip off

Treatment philosophy

ConservativeRestriction of inciting activity

SurgeryTo restore normal roll and glide of the jointExcision 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 trimOPEN/ ARTHROSCOPIC/ ARTHROSCOPY+OPEN

The Labrum

Increases containment / inreases stabilitySuction socket principle – creates a fluid film

that prevents close contact within the joint

EVIDENCERoutine repair of the labrum resulted in

higher clinical scores in studies that compared labral repair 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

EVIDENCESustained improvement in clinical scores after

isolated labral débridement of various patterns of labral damage 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 27-48June 2011- June 2013 / follow up 13m – 36mDiagnosis

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 FAICartilage status evaluated by OUTERBRIDGE SCALEPost op follow up at 1m/2m/6m/6monthlyFU evaluated by Roles-modesly Score / Oxford Hip

ScoreHip 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–Maudsley Score

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

LabAet

Technique

Case 2

Fem hdL

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 + head osteophyte removal

3 4/37 3 2 2/42

4 AVN Labrectomy + head osteophyte removal

3 4/40 3 2 2/44

5 Perthes Labrectomy + head osteophyte removal

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

6 Idiopathic Labrectomy + cam removal

3 4/34 3 2 2/44

7 Idiopathic Labrectomy + cam removal

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

8 Idiopathic Labrectomy + cam removal

4 4/39 3 2 2/45

8 Idiopathic Labrectomy + cam removal

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.

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