dr m.n.basu mallick arthroscopy and sports surgery apollo gleneagles hospital, kolkata...
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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.
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.