DR M.N.BASU MALLICK ARTHROSCOPY AND SPORTS SURGERY APOLLO 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 MRI Kassarjian 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 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 EVIDENCE Sustained 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 June 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–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 Lab Aet

Technique

Case 2 Fem hd L

Case 3 Fem hd lab Acet

Case 4 Fem hd L Acet

Case 5

Results SL N O DIAGPROCEDURE OUTE RBRID GE PRE- OP RM/Ox 2M6M1YR2YR3YR 1 OsteophyteLabrectomy + rim trim44/33322/432/42 2 OsteophyteLabrectomy + rim trim24/34322/43 3 OsteophyteLabrectomy + rim trim44/37322/43 4 AVNLabrectomy + head osteophyte removal 34/37322/42 4 AVNLabrectomy + head osteophyte removal 34/40322/44 5 PerthesLabrectomy + head osteophyte removal 44/37323/403/413 6 IdiopathicLabrectomy + cam removal 34/34322/44 7 IdiopathicLabrectomy + cam removal 44/38333/402/422 8 IdiopathicLabrectomy + cam removal 44/39322/45 8 IdiopathicLabrectomy + cam removal 34/37322/44

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.