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Arthroscopic Labralization of the Hip: An Alternative to Labral Reconstruction
Arthroscopic Labralization of the Hip: An Alternative to Labral Reconstruction Dean K. Matsuda, M.D.
Abstract: Labralization, which may be performed by open or arthroscopic means, may be an attractive alternative to hip labral reconstruction. By preserving the articular cartilage in the region of labral deficit with meticulous rim trimming, the resultant undermined free chondral margin (“pseudolabrum”) may immediately restore a fluid seal function and may theoretically enhance hip preservation. Arthroscopic hip labralization is a relatively simple and fast procedure without graft harvest morbidity. It may be performed in patients tolerating rim reduction with encouraging preliminary outcomes.
A
rthroscopic hip labral reconstruction has been used in the management of severe labral insufficiency in hopes of restoring labral function and enhancing hip preservation.1-6 Optimal candidates may be relatively young active patients without significant coxarthrosis.1-7 For patients with non-salvageable labra who are older and/or have somewhat more chondral damage, we have developed an arthroscopic alternative to labral debridement or reconstruction.
Surgical Technique The key to labralization is selective burr resection of the bony acetabular rim without resection of its articular cartilage. Rim trimming with a burr is performed through the modified mid-anterior portal. This working portal facilitates trimming of the acetabular rim from the peripheral compartment or capsular side of the preexisting labrum in the region of labral insufficiency. By preserving the articular cartilage in the region of labral deficit with meticulous rim trimming, the resultant undermined free chondral margin (“pseudolabrum”) may immediately restore a fluid seal function and may theoretically enhance hip preservation (Figs 1 and 2). From Kaiser West Los Angeles Medical Center, Los Angeles, California, U.S.A. The author reports the following potential conflict of interest or source of funding: ArthroCare and Smith & Nephew for intellectual properties. Received July 29, 2013; accepted September 6, 2013. Address correspondence to Dean K. Matsuda, M.D., Kaiser West Los Angeles Medical Center, 6041 Cadillac Ave, Los Angeles, CA 90034, U.S.A. E-mail: [email protected] Ó 2014 by the Arthroscopy Association of North America 2212-6287/13525/$36.00 http://dx.doi.org/10.1016/j.eats.2013.09.009
A round burr may be used but will result in a crosssectional U-shaped trough at the trimmed rim. Although one can burr down the resultant prominent ridges, to do so with a round burr at the critical subchondral boneearticular cartilageelabrum interface causes some burr-induced damage to the adjacent chondrolabral tissue. New burr designs (flat-top burr; Smith & Nephew, Andover, MA) facilitate optimized rim trimming while preserving the chondrolabral tissue (Figs 3 and 4). The high-visibility sheath of the flat-top burr aids controlled bony rim trimming whereas the distal sheath acts as a retractor, protecting the articular cartilage as it is incrementally exposed during rim resection. We desire an intact junction for the pseudolabrum; any areas of even subtle chondral delamination undergo incremental rim trimming to a stable rim construct. Only enough rim resection to yield a sufficient pseudolabrum is required, although in select cases 1 cm of rim width may be needed to treat extreme global pincer deformities with severe acetabular over-coverage. The fluoroscopic templating technique8 may be used to ensure precision rim trimming. Shaping and blending of the pseudolabrum with the native labral margins are performed with a radiofrequency ablator with a built-in thermocouple sensing adjacent fluid temperatures approaching 45 C (HipVac 50; ArthroCare, Austin, TX) so as to avoid chondrocyte death, which may occur above 50 C.9-13 Arthroscopic shaving may be used to remove any potential heatdamaged tissue. Debulking of excessively large sections of pseudolabrum is performed in a likewise manner to approximate the native labrum in gross appearance and to minimize the risk of a pseudolabral tear at excessively wide sections. Suture anchor augmentation may
Arthroscopy Techniques, Vol 3, No 1 (February), 2014: pp e131-e133
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D. K. MATSUDA
Fig 1. Animated image showing region of acetabular labral deficiency before labralization.
be performed, but we have not found this to be indicated in most cases. Video 1 demonstrates the surgical technique.
Fig 3. Supine arthroscopic image of right hip viewed from anterolateral portal during rim trimming with flat-top burr while protecting/preserving undermined acetabular articular cartilage with protective shield.
By restoration of the labral fluid seal effect for symptomatic improvement and theoretical hip preservation, arthroscopic labral reconstruction is emerging with encouraging outcomes.1-7 Patients with severe anatomic and/or functional labral insufficiency deemed borderline candidates for reconstruction may benefit from hip labralization as an attractive alternative to labrectomy or reconstruction.7 It is a relatively simple and quick procedure without graft harvest morbidity or allograft costs that can be performed in patients undergoing rim reduction.7 A recent cadaveric study showed a relatively poor fluid seal effect after labral reconstruction at time 0 compared with the intact labrum and repaired labrum.14 Labralization, which
may be performed with open or arthroscopic techniques, offers the potential for immediate fluid seal restoration because there is no fixated labral or graft tissue to eventually provide a “healed and sealed” effect; the pseudolabrum is in continuity with the remaining acetabular articular cartilage. Labralization requires acetabular rim trimming and hence is limited to acetabula appropriate for rim reduction. Pincer femoroacetabular impingement morphology, whether global or focal, is amenable to this procedure. Theoretically, a normal acetabulum may tolerate some degree of rim reduction and may be amenable to labralization; however, Leunig and colleagues15 have recommended that rim trimming be limited to a reduction in the radiographic center-edge angle not less than 20 . A contraindication to labralization is a dysplastic hip with
Fig 2. Animated image immediately after arthroscopic labralization with a burr. One should note the chondral free margin (pseudolabrum), which has been exposed after meticulous rim trimming.
Fig 4. Arthroscopic image immediately after arthroscopic labralization.
Discussion
e133
ARTHROSCOPIC LABRALIZATION OF HIP Table 1. Relative Pros and Cons of Arthroscopic Labralization Versus Labral Reconstruction Labralization Labral Reconstruction Speed Ease Graft harvest morbidity Able to use in cases of dysplasia
þþþ þþþ þþþ e
e e e þþþ
þþþ, strong advantage; e, disadvantage.
a shallow socket that cannot tolerate rim reduction; a relative advantage of labral reconstruction is that it may be performed if indicated in that setting7 (Table 1). Arthroscopic labralization was originally developed as an alternative to labral reconstruction in patients deemed not good candidates for the latter. In general, older patients (aged >50 years) and/or those with early degenerative changes underwent labralization because we could not justify the extra morbidity and operative time of labral reconstruction but did not want to leave them with significant segmental labral deficiency. Unfortunately, this selection bias prevents valid comparison with outcomes from arthroscopic labral reconstruction. However, if successful clinical outcomes are observed in this cohort, the indications for arthroscopic labralization may expand to younger nonarthritic patients, which may then permit valid comparison with labral reconstruction. Preliminary outcomes from arthroscopic labralization have been reported recently.7 Six patients with a mean age of 47 years (range, 37 to 54 years), a preoperative diagnosis of cam-pincer femoroacetabular impingement, and a mean follow-up of 21 months (range, 12 to 35 months) underwent arthroscopic hip labralization along with acetabulo-femoroplasty. The preoperative Non-Arthritic Hip Score averaged 52 (range, 24 to 77) and the postoperative score averaged 90 (range, 76 to 100), with a mean improvement of 38 (range, 9 to 63) (P ¼ .031). Patient-assessed satisfaction was high. There were no complications, revision surgeries, or conversions to arthroplasty. Expanded longer-term studies are ongoing to determine whether the initial encouraging findings are durable, hip-preservative, and comparable to those of labral reconstruction if studied in similar cohorts. Arthroscopic hip labralization is a relatively simple and fast procedure without graft harvest morbidity that has the potential for immediate labral fluid seal restoration. As such, it may be an attractive alternative to labral reconstruction. It may be performed in patients tolerating rim reduction with encouraging preliminary outcomes.
References 1. Sierra RJ, Trousdale RT. Labral reconstruction using the ligamentum teres capitis: Report of a new technique. Clin Orthop Relat Res 2009;467:753-759. 2. Philippon MJ, Briggs KK, Hay CJ, Kuppersmith DA, Dewing CB, Huang MJ. Arthroscopic labral reconstruction in the hip using iliotibial band autograft: Technique and early outcomes. Arthroscopy 2010;26:750-756. 3. Matsuda DK. Arthroscopic labral reconstruction with gracilis autograft. Arthrosc Tech 2012;1:e15-e21. 4. Walker JA, Pagnotto M, Trousdale RT, Sierra RJ. Preliminary pain and function after labral reconstruction during femoroacetabular impingement surgery. Clin Orthop Relat Res 2012;470:3414-3420. 5. Geyer MR, Philippon MJ, Fagrelius TS, Briggs KK. Acetabular labral reconstruction with an iliotibial band autograft: Outcome and survivorship analysis at minimum 3-year follow-up. Am J Sports Med 2013;41: 1750-1756. 6. Matsuda DK, Burchette RJ. Arthroscopic hip labral reconstruction with a gracilis autograft versus labral refixation: 2-year minimum outcomes. Am J Sports Med 2013;41:980-987. 7. Matsuda DK. Arthroscopic hip labral reconstruction: Graft choices, techniques, and advances. Tech Orthop 2012;27: 184-192. 8. Matsuda DK. Fluoroscopic templating technique for precision arthroscopic rim trimming. Arthroscopy 2009;25: 1175-1182. 9. Voss JR, Lu Y, Edwards RB, Bogdanske JJ, Markel MD. Effects of thermal energy on chondrocyte viability. Am J Vet Res 2006;67:1708-1712. 10. Zoric BB, Horn N, Braun S, Millett PJ. Factors influencing intra-articular fluid temperature profiles with radiofrequency ablation. J Bone Joint Surg Am 2009;91: 2448-2454. 11. Chu CR, Kaplan LD, Fu FH, Crossett LS, Studer RK. Recovery of articular cartilage metabolism following thermal stress is facilitated by IGF-1 and JNK inhibitor. Am J Sports Med 2004;32:191-196. 12. Good CR, Shindle MK, Griffith MH, Wanich T, Warren RF. Effect of radiofrequency energy on glenohumeral fluid temperature during shoulder arthroscopy. J Bone Joint Surg Am 2009;91:429-434. 13. Piper SL, Kim HT. Thermal stress potentiates bupivacaine chondrotoxicity. Arthroscopy 2012;28:1246-1254.e1. Available online at www.arthroscopyjournal.org. 14. Cadet ER, Chan AK, Vorys GC, Gardner T, Yin B. Investigation of the preservation of the fluid seal effect in the repaired, partially resected, and reconstructed acetabular labrum in a cadaveric hip model. Am J Sports Med 2012;40: 2218-2223. 15. Espinosa N, Beck M, Rothenfluh DA, Ganz R, Leunig M. Treatment of femoro-acetabular impingement: Preliminary results of labral refixation. Surgical technique. J Bone Joint Surg Am 2007;89(suppl 2, pt 1):36-53.
Abstract: Labralization, which may be performed by open or arthroscopic means, may be an attractive alternative to hip labral reconstruction. By preserving the articular cartilage in the region of labral deficit with meticulous rim trimming, the resultant undermined free chondral margin (“pseudolabrum”) may immediately restore a fluid seal function and may theoretically enhance hip preservation. Arthroscopic hip labralization is a relatively simple and fast procedure without graft harvest morbidity. It may be performed in patients tolerating rim reduction with encouraging preliminary outcomes.
A
rthroscopic hip labral reconstruction has been used in the management of severe labral insufficiency in hopes of restoring labral function and enhancing hip preservation.1-6 Optimal candidates may be relatively young active patients without significant coxarthrosis.1-7 For patients with non-salvageable labra who are older and/or have somewhat more chondral damage, we have developed an arthroscopic alternative to labral debridement or reconstruction.
Surgical Technique The key to labralization is selective burr resection of the bony acetabular rim without resection of its articular cartilage. Rim trimming with a burr is performed through the modified mid-anterior portal. This working portal facilitates trimming of the acetabular rim from the peripheral compartment or capsular side of the preexisting labrum in the region of labral insufficiency. By preserving the articular cartilage in the region of labral deficit with meticulous rim trimming, the resultant undermined free chondral margin (“pseudolabrum”) may immediately restore a fluid seal function and may theoretically enhance hip preservation (Figs 1 and 2). From Kaiser West Los Angeles Medical Center, Los Angeles, California, U.S.A. The author reports the following potential conflict of interest or source of funding: ArthroCare and Smith & Nephew for intellectual properties. Received July 29, 2013; accepted September 6, 2013. Address correspondence to Dean K. Matsuda, M.D., Kaiser West Los Angeles Medical Center, 6041 Cadillac Ave, Los Angeles, CA 90034, U.S.A. E-mail: [email protected] Ó 2014 by the Arthroscopy Association of North America 2212-6287/13525/$36.00 http://dx.doi.org/10.1016/j.eats.2013.09.009
A round burr may be used but will result in a crosssectional U-shaped trough at the trimmed rim. Although one can burr down the resultant prominent ridges, to do so with a round burr at the critical subchondral boneearticular cartilageelabrum interface causes some burr-induced damage to the adjacent chondrolabral tissue. New burr designs (flat-top burr; Smith & Nephew, Andover, MA) facilitate optimized rim trimming while preserving the chondrolabral tissue (Figs 3 and 4). The high-visibility sheath of the flat-top burr aids controlled bony rim trimming whereas the distal sheath acts as a retractor, protecting the articular cartilage as it is incrementally exposed during rim resection. We desire an intact junction for the pseudolabrum; any areas of even subtle chondral delamination undergo incremental rim trimming to a stable rim construct. Only enough rim resection to yield a sufficient pseudolabrum is required, although in select cases 1 cm of rim width may be needed to treat extreme global pincer deformities with severe acetabular over-coverage. The fluoroscopic templating technique8 may be used to ensure precision rim trimming. Shaping and blending of the pseudolabrum with the native labral margins are performed with a radiofrequency ablator with a built-in thermocouple sensing adjacent fluid temperatures approaching 45 C (HipVac 50; ArthroCare, Austin, TX) so as to avoid chondrocyte death, which may occur above 50 C.9-13 Arthroscopic shaving may be used to remove any potential heatdamaged tissue. Debulking of excessively large sections of pseudolabrum is performed in a likewise manner to approximate the native labrum in gross appearance and to minimize the risk of a pseudolabral tear at excessively wide sections. Suture anchor augmentation may
Arthroscopy Techniques, Vol 3, No 1 (February), 2014: pp e131-e133
e131
e132
D. K. MATSUDA
Fig 1. Animated image showing region of acetabular labral deficiency before labralization.
be performed, but we have not found this to be indicated in most cases. Video 1 demonstrates the surgical technique.
Fig 3. Supine arthroscopic image of right hip viewed from anterolateral portal during rim trimming with flat-top burr while protecting/preserving undermined acetabular articular cartilage with protective shield.
By restoration of the labral fluid seal effect for symptomatic improvement and theoretical hip preservation, arthroscopic labral reconstruction is emerging with encouraging outcomes.1-7 Patients with severe anatomic and/or functional labral insufficiency deemed borderline candidates for reconstruction may benefit from hip labralization as an attractive alternative to labrectomy or reconstruction.7 It is a relatively simple and quick procedure without graft harvest morbidity or allograft costs that can be performed in patients undergoing rim reduction.7 A recent cadaveric study showed a relatively poor fluid seal effect after labral reconstruction at time 0 compared with the intact labrum and repaired labrum.14 Labralization, which
may be performed with open or arthroscopic techniques, offers the potential for immediate fluid seal restoration because there is no fixated labral or graft tissue to eventually provide a “healed and sealed” effect; the pseudolabrum is in continuity with the remaining acetabular articular cartilage. Labralization requires acetabular rim trimming and hence is limited to acetabula appropriate for rim reduction. Pincer femoroacetabular impingement morphology, whether global or focal, is amenable to this procedure. Theoretically, a normal acetabulum may tolerate some degree of rim reduction and may be amenable to labralization; however, Leunig and colleagues15 have recommended that rim trimming be limited to a reduction in the radiographic center-edge angle not less than 20 . A contraindication to labralization is a dysplastic hip with
Fig 2. Animated image immediately after arthroscopic labralization with a burr. One should note the chondral free margin (pseudolabrum), which has been exposed after meticulous rim trimming.
Fig 4. Arthroscopic image immediately after arthroscopic labralization.
Discussion
e133
ARTHROSCOPIC LABRALIZATION OF HIP Table 1. Relative Pros and Cons of Arthroscopic Labralization Versus Labral Reconstruction Labralization Labral Reconstruction Speed Ease Graft harvest morbidity Able to use in cases of dysplasia
þþþ þþþ þþþ e
e e e þþþ
þþþ, strong advantage; e, disadvantage.
a shallow socket that cannot tolerate rim reduction; a relative advantage of labral reconstruction is that it may be performed if indicated in that setting7 (Table 1). Arthroscopic labralization was originally developed as an alternative to labral reconstruction in patients deemed not good candidates for the latter. In general, older patients (aged >50 years) and/or those with early degenerative changes underwent labralization because we could not justify the extra morbidity and operative time of labral reconstruction but did not want to leave them with significant segmental labral deficiency. Unfortunately, this selection bias prevents valid comparison with outcomes from arthroscopic labral reconstruction. However, if successful clinical outcomes are observed in this cohort, the indications for arthroscopic labralization may expand to younger nonarthritic patients, which may then permit valid comparison with labral reconstruction. Preliminary outcomes from arthroscopic labralization have been reported recently.7 Six patients with a mean age of 47 years (range, 37 to 54 years), a preoperative diagnosis of cam-pincer femoroacetabular impingement, and a mean follow-up of 21 months (range, 12 to 35 months) underwent arthroscopic hip labralization along with acetabulo-femoroplasty. The preoperative Non-Arthritic Hip Score averaged 52 (range, 24 to 77) and the postoperative score averaged 90 (range, 76 to 100), with a mean improvement of 38 (range, 9 to 63) (P ¼ .031). Patient-assessed satisfaction was high. There were no complications, revision surgeries, or conversions to arthroplasty. Expanded longer-term studies are ongoing to determine whether the initial encouraging findings are durable, hip-preservative, and comparable to those of labral reconstruction if studied in similar cohorts. Arthroscopic hip labralization is a relatively simple and fast procedure without graft harvest morbidity that has the potential for immediate labral fluid seal restoration. As such, it may be an attractive alternative to labral reconstruction. It may be performed in patients tolerating rim reduction with encouraging preliminary outcomes.
References 1. Sierra RJ, Trousdale RT. Labral reconstruction using the ligamentum teres capitis: Report of a new technique. Clin Orthop Relat Res 2009;467:753-759. 2. Philippon MJ, Briggs KK, Hay CJ, Kuppersmith DA, Dewing CB, Huang MJ. Arthroscopic labral reconstruction in the hip using iliotibial band autograft: Technique and early outcomes. Arthroscopy 2010;26:750-756. 3. Matsuda DK. Arthroscopic labral reconstruction with gracilis autograft. Arthrosc Tech 2012;1:e15-e21. 4. Walker JA, Pagnotto M, Trousdale RT, Sierra RJ. Preliminary pain and function after labral reconstruction during femoroacetabular impingement surgery. Clin Orthop Relat Res 2012;470:3414-3420. 5. Geyer MR, Philippon MJ, Fagrelius TS, Briggs KK. Acetabular labral reconstruction with an iliotibial band autograft: Outcome and survivorship analysis at minimum 3-year follow-up. Am J Sports Med 2013;41: 1750-1756. 6. Matsuda DK, Burchette RJ. Arthroscopic hip labral reconstruction with a gracilis autograft versus labral refixation: 2-year minimum outcomes. Am J Sports Med 2013;41:980-987. 7. Matsuda DK. Arthroscopic hip labral reconstruction: Graft choices, techniques, and advances. Tech Orthop 2012;27: 184-192. 8. Matsuda DK. Fluoroscopic templating technique for precision arthroscopic rim trimming. Arthroscopy 2009;25: 1175-1182. 9. Voss JR, Lu Y, Edwards RB, Bogdanske JJ, Markel MD. Effects of thermal energy on chondrocyte viability. Am J Vet Res 2006;67:1708-1712. 10. Zoric BB, Horn N, Braun S, Millett PJ. Factors influencing intra-articular fluid temperature profiles with radiofrequency ablation. J Bone Joint Surg Am 2009;91: 2448-2454. 11. Chu CR, Kaplan LD, Fu FH, Crossett LS, Studer RK. Recovery of articular cartilage metabolism following thermal stress is facilitated by IGF-1 and JNK inhibitor. Am J Sports Med 2004;32:191-196. 12. Good CR, Shindle MK, Griffith MH, Wanich T, Warren RF. Effect of radiofrequency energy on glenohumeral fluid temperature during shoulder arthroscopy. J Bone Joint Surg Am 2009;91:429-434. 13. Piper SL, Kim HT. Thermal stress potentiates bupivacaine chondrotoxicity. Arthroscopy 2012;28:1246-1254.e1. Available online at www.arthroscopyjournal.org. 14. Cadet ER, Chan AK, Vorys GC, Gardner T, Yin B. Investigation of the preservation of the fluid seal effect in the repaired, partially resected, and reconstructed acetabular labrum in a cadaveric hip model. Am J Sports Med 2012;40: 2218-2223. 15. Espinosa N, Beck M, Rothenfluh DA, Ganz R, Leunig M. Treatment of femoro-acetabular impingement: Preliminary results of labral refixation. Surgical technique. J Bone Joint Surg Am 2007;89(suppl 2, pt 1):36-53.