Circumferential reconstruction of severe acetabular labral damage using hamstring allograft: surgical technique and case series.

DOI: 10.5301/HIP.2013.11662

Hip Int 2013 ; 23 ( Suppl 9) : S42 - S53

ORIGINAL ARTICLE

Circumferential reconstruction of severe acetabular labral damage using hamstring allograft: surgical technique and case series Pedro Costa Rocha 1, Gregory Klingenstein 2, Reinhold Ganz 3, Bryan T. Kelly 2, Michael Leunig 4 Study performed at the Department of Orthopaedics, Schulthess Clinic, Zürich - Switzerland Orthopaedics Department, Hospital de Santa Maria - CHLN, Lisbon - Portugal Center for Hip Preservation, Hospital for Special Surgery, New York - USA 3 Medical Faculty, University of Berne, Berne - Switzerland 4 Hip Service, Schulthess Clinic, Zürich - Switzerland 1 2

Introduction: With excessive acetabular coverage, such as coxa profunda or protrusio, contact bet ween the femoral neck and acetabular rim cause direct damage to the labrochondral junction, and indirect edge loading from a levering effect which may result in hip arthrosis. Arthrosis may be delayed or avoided by addressing the overcoverage and restoring mechanical function of the labrum. We de scribe four cases of adjunctive complete acetabular labral replacement for circumferential, irreparable labral injury using fresh frozen semitendinous allografts through surgical hip dislocation. Materials and Methods: Over a two-year period four patients (age range: 20 to 47 years) under went surgical hip dislocation to address femoroacetabular impingement with rim trimming, femoral osteochondroplasty, and labral reconstruction. Pre- and postoperative patient reported outcomes were assessed by Oxford Hip Score (OHS), Hip Outcome Score (HOS), and Global Treatment Out come (GTO) score. Disease progression was graded using AP pelvic radiographs and arthroMR. Results: The average LCE correction was 18º (range 7-25º), achieving an average LCE of 33º (range 32-35) postoperatively. Using protected weight bearing all trochanteric osteotomies healed within six weeks after surgery. OA did not progress in any hips. Mean OHS and HOS scores improved 6.3 and 19.8 at one-year follow up. All four patients reported good results according to the GTO. There were two adverse events that resolved and did not affect outcome. Summary and conclusions: Despite complex deformities and preexisting cartilage and labrum wear in this young cohort, three of four patients reported significant functional improvement after treatment of this rare condition. Preliminary experience with circumferential labral reconstruction using ham string allografts is promising, although long-term data needs to be established. Keywords: Femoroacetabular impingement, Global pincer, Labral tear/degeneration, Labrum reconstruction Accepted: June 15, 2012

INTRODUCTION Injury to the acetabular labrum most frequently results from trauma (1), developmental dysplasia (2) and femoroacetabular impingement (FAI) (3, 4). Structural abnormaliS42

ties of the acetabulum contributing to FAI consist of either focal or global overcoverage, as seen in coxa profunda or protrusion (4, 5). In contrast to cam FAI, the primary injury mechanism of pincer FAI is repetitive impaction of the femoral neck against the acetabular rim, leading to labral de-

© 2013 Wichtig Editore - ISSN 1120-7000

Costa Rocha et al

generation and intrasubstance degeneration (4, 6). Recent histologic findings suggested that the conflict between the femoral neck and labrum may initiate subperiosteal bone apposition at the acetabular rim, which results in osseus encasement of the labrum on the capsular side, further compromising its functional integrity (7). An intact acetabular labrum is thought to play a pivotal role in hip biomechanics (1, 2, 6, 8). This fibrocartilaginous structure inserts along the free margin of the bony acetabulum and continues across the acetabular notch, where it runs in continuity with the transverse acetabular ligament, forming a complete circle enclosing the femoral head around its equator (6). The labrum increases acetabular surface area by 27% and volume by 30% (9). Additionally, the acetabular labrum limits synovial fluid extrusion from the central compartment during joint loading. Lastly, the labrum maintains a suction seal that resists distraction of the femoral head from the acetabulum, thus increasing joint stability (8, 10). Given the important contributions of the labrum to normal hip biomechanics, labral preservation or restoration would seem intuitive. Labral repair combined with surgical correction of FAI has been shown to produce better clinical outcomes than labral excision alone (11, 12). In a scenario where labral injury is too advanced for repair, labral reconstruction has been proposed to restore integrity of the labro-acetabular complex. Philippon et al (13-15) described an arthroscopic technique for reconstruction of partial labral defects using iliotibial band autograft. Alternatively, Sierra and Trousdale (16) report a technique for the reconstruction of partial labral lesions via surgical hip

dislocation using the ligamentum teres capitis as autograft. The purpose of this paper was to describe technical aspects and our preliminary experience with reconstruction of circumferential, irreparable labral damage due to rim ossification with semitendinosis allograft through surgical hip dislocation. Additionally, we report the rationale and surgical technique for open acetabular rim trimming with labral reconstruction for global overcoverage.

MATERIALS AND METHODS Informed consent was obtained from all patients, and our ethical review committee approved this study. Between February 2010 and February 2012, a small case series of four patients received surgical hip dislocation to address femoroacetabular impingement and labrum reconstruction using fresh frozen semitendinosis tendon allografts. There were three women and one man with an average age of 33 years (range 20-47). All had prolonged hip pain exacerbated by sitting, standing and activity that referred to the anterior hip or groin. On physical examination three patients had less than 16 degrees of internal rotation at 90º of hip flexion (Tab. I). All patients had a positive dynamic internal rotation impingement test and two also had a positive dynamic external rotation impingement test, that recreated the patients’ pain. There were two patients with coxa profunda (patients 1 and 3) and two with protrusio acetabuli (patients 2 and 4). In all patients the acetabular version was normal based

TABLE I - PATIENT DEMOGRAPHICS, CLINICAL PRESENTATION AND PHYSICAL EXAM Patient 1

Patient 2

Patient 3

Patient 4

Gender/Age

F/47

M/20

F/42

F21

Height (cm) / Weight (Kg)

161/50

209/88

183/89

173/63

Duration of pain

3M

2Y

3Y

6Y

Pain location

Groin

Groin

Groin

Groin

Exacerbating activity

Exercise

Standing

Sitting

Exercise

Comorbidities

No

No

Multiple sclerosis

No

Previous hip surgery

No

No

Hip arthroscopy

No

Range of motion (flexion, internal rotation, exernal rotation)

100-40-45º

90-10-15º

95-15-35º

100-10-10º


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Allograft reconstruction of the acetabular labrum

on an AP pelvis radiograph. A small superior cross-over sign for patient 3 was previously corrected during a prior hip arthroscopy. The average acetabular index (AI) was -10º (range 0 to -17). The mean preoperative lateral center edge angle (LCE) was 50º (range 39-59º). As for the proximal femur, the average neck-shaft angle was 129º (range 127-132º), and three of the four patients also had reduced head-neck offset with an average alpha angle of 64º (range 60-68º). FAI was categorised as global pincer FAI in all patients, with concurrent cam FAI in three patients (Tab. II). Magnetic resonance arthrogram (MRA) of the hip was part of preoperative evaluation in each case. All patients underwent a surgical hip dislocation as des cribed by Ganz et al (17), performed by the senior author (ML). Trochanteric step cut osteotomies were used in three of the four patients allowing early full weight bearing. Correction of the femoral head-neck offset was performed in three patients. Femoral and acetabular cartilage lesions were treated by local debridement and first generation microfracture techniques when necessary. One patient also required trochanteric advancement for coxa vara with a short femoral neck and high riding trochanter (patient 4). The average surgical time was 159 minutes (range 150200’) and average blood loss 338 ml in this series. Oxford Hip Scores (OHS) and Hip Outcome Score Activities of Daily Living (HOS ADL) were obtained before surgery and at latest follow-up (18, 19). Overall satisfaction with treatment was evaluated based on Global Treatment Outcome (GTO), in which patients report that the intervention “did not help,” “helped a little,” “helped,” or “helped a lot” (20).

Surgical technique The patient was placed in the lateral decubitus position. A straight lateral incision of approximately 20 to 25 cm in length was made along the anterior border of the greater trochanter. The fascia lata was incised in line with the incision and extended proximally without any violation of the gluteus maximus fibres. The intergluteal space was then developed and the posterocranial tip of the trochanter was identified and palpated. A triplanar trochanteric osteotomy was performed. The trochanteric fragment should provide continuity between the gluteus medius and the gluteus minimus (specifically the long tendon anteriorly) proximally and the vastus lateralis via the osteotomy fragment distally. Thus, the osteotomy is trigastric rather than digastric in nature. Conversely, the piriformis and the short external rotators should remain attached to the nonosteotomised femur (i.e., the stable trochanter). Although the osteotomy was originally described as a single plane cut, we now recommend using a triplanar osteotomy to increase the mechanical stability of the osteotomy fragment to allow earlier weight bearing. One exception to the step-cut osteotomy would be if a trochanteric advancement is required (as we did in patient 4). Next, the osteotomy fragment was mobilised. Care must be taken during this portion of the procedure to avoid any damage to the short external rotators, particularly the obturator externus tendon in close proximity to the ascending branch of the medial femoral circumflex artery. The following step was to develop and expose the hip capsule between the interval of the gluteus minimus and the piriformis. After the

TABLE II - RADIOGRAPHIC FINDINGS BEFORE SURGERY Patient 1

Patient 2

Patient 3

Patient 4

Tonnis grade

1

1

0

1

Acetabular depth (head to ilioischial line distance)

Coxa profunda (5mm)

Coxa protrusio (-3mm)

Coxa profunda (5mm)

Coxa protrusio (-2mm)

Acetabular version

Normal

Normal

Small superior cross-over sign

Normal

Acetabular index

-10º

-17º

0º

-11º

Lateral center edge angle

54º

59º

39º

52º

Alpha angle

68º

63º

60º

54º

Neck-shaft angle

128º

127º

132º

127º

FAI mechanism

Pincer > Cam

Pincer >> Cam

Pincer > Cam

Pincer >>> Cam

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gradual release of the insertions of the gluteus minimus from the capsule, the hip capsule was completely exposed. Now, a z-shaped capsulotomy (viewed for the right side) was performed. The labrum and the chondral surfaces were protected using an “inside-out” arthrotomy, which ensures the visualization of these structures. The next step was the dislocation of the femoral head and the positioning of the retractors to visualise the pathology. A blunt retractor was placed around the femoral calcar, and the hip was gently subluxed. In deep hips, this step is much more demanding than in hips with normal coverage (and might lead to local damage as seen in patient 3 with an ectopic ossification at the anterior inferior iliac spine). The ligamentum teres, which prevents complete dislocation, has to be cut with parametrium scissors if still intact. In deep acetabuli the ligamentum teres is often degenerated and incompetent because of the close proximity of the femoral head and the acetabular fossa. The femoral head was then dislocated anteriorly and the lower extremity placed in the sterile leg bag. At this point there was a 360-degree view of the entire acetabulum so the hip could be inspected for evidence of injury to the labrum and chondral surfaces. In all four patients the labrum was almost completely absent due to rim ossification of repetitive direct damage and therefore unsalvageable. The acetabular fossa was also significantly increased with a normal sized but flat horse shoe. Rim excision was performed with curved osteotomes to resolve the impingement as much as possible, but limited by the size of the horse shoe (articular surface). In deep sockets therefore, normalization of the lateral center edge angle in protrusio hips is frequently not possible since it would require resecting most of the weight bearing horse shoe. Once the rim trimming was performed, the residual acetabular chondral lesions were addressed through debridement and microfracture when necessary. In all the patients a total labrum reconstruction was performed with fresh frozen semitendinous allograft. In this series, an average of eight titanium anchors were placed into the bed of bleeding cancellous bone approximately 10 mm to 15 mm apart. The nonabsorbable suture of the anchor was passed through the base of the labrum and tied with the labrum firmly seated against the acetabular bone so that the knot lies on the capsular side of the labrum. Once attached to the acetabular rim, the neo-labrum was sutured to the transverse acetabular ligament with simple stitches using reabsorbable suture, completing the entire 360º reconstruction.

When addressing the femoral head, first the posterosuperior retinaculum and the vessels were identified and protected. Next, the sphericity of the femoral head could be assessed with the use of appropriately sized transparent spherical templates. The impinging bone was removed carefully with the use of curved osteotomes until a normal head–neck offset was recreated, with care taken not to injure the terminal branches of the MFCA laterally. In two patients a perifoveal osteophyte was excised and the cartilage defects were microfractured. After relocation of the femoral head in the acetabulum, the range of motion was then assessed for any residual impingement and the presence of a suction seal was confirmed. Capsular closure was performed without excessive tension to avoid the compromise to the retinacular vessels. The trochanteric fragment was reduced anatomically according to the triplanar osteotomy step cuts and reattached with the use of 3.5 mm or 4.5 mm screws. All the patients underwent a similar rehabilitation protocol: use of a CPM machine the first day after surgery, toe-touch weight bearing with crutches, and hip flexion limited flexion to 90º for six weeks. After that time, gradual progression to full weight bearing and full range of motion was initiated. Clinical and radiographic evaluation was obtained at six weeks, three, six and twelve months and every year after that.

RESULTS After surgical correction the centre edge angle of the four patients went from 54° to 33°, 59° to 34°, 39° to 32°, and 53° to 35°. The average follow-up was 19 months (range 6-30). At latest follow-up the mean OHS improved from 30 (range 24 to 35) to 36 (range 19 to 47). Likewise, the mean HOS improved from 59.5 (range 45.6 to 79.4) to 79.3 (range 41.2 to 100). Two patients reported that the surgery “helped a lot” and two patients reported “it helped” according to the GTO score. No patient required hip arthroplasty or revision intra-articular surgery, and there were no radiographic signs of significant progressive arthrosis at the latest evaluation. Summary of intraoperative findings and results are presented in Tables III and IV.

CASE SERIES Patient 1 is a highly athletic 47-year-old nurse, who competes in masters badminton tournaments. Despite a sig-


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TABLE III - INTRAOPERATIVE FINDINGS, PROCEDURE, AND RADIOGRAPHIC RESULT Patient 1

Patient 2

Patient 3

Patient 4

Status of labrum

Calcified

Calcified, 1-2 mm

Calcified/Previously resected

Calcified, 2-3 mm

Rim trimming

Yes

Yes

Yes

Yes

Graft

Semi tendinous allograft




Number of anchors

7

9

7

8

Cam resection

Yes

Yes

Yes

No

Cartilage lesion (Beck grade)

No

Acetabulum: posteroinferior (II-III)

Acetabulum – antero superior, postero inferior condromalacia

Acetabulum: anteroinferior and posteroinferior (II-III) Femoral head: fovea osteophyte

Femoral head: fovea osteophyte Microfracture

No

Acetabulum posteroinferior Femoral head peri-foveal

No

Acetabulum posteroinferior

Surgical time, blood loss

135’/300 ml

200’/350 ml

150’/300 ml

150’/400 ml

Postoperative lateral center edge angle

32º

34º

32º

35º

Postoperative alpha angle

46

52

50

n/a

TABLE IV - PATIENT REPORTED CLINICAL RESULTS Patient 1

Patient 2

Patient 3

Patient 4

Mean

OHS baseline

31

35

24

30

30

OHS 12 month

47

39

19

40

36.3

HOS baseline

79.4

50

45.6

63

59.5

HOS 12 month

100

85

41.2

91

79.3

Helped a lot

Helped

Helped

Helped a lot

GTO

OHS: Oxford Hip Score, HOS: Hip Outcome score (activity of daily living component), GTO: Global Treatment Outcome score.

nificant intraosseous anterior wall cyst before surgery, she reported excellent clinical results at her two-years followup visit. There were no postoperative complications, and she went on to win the National Badminton Championship (Fig. 1). Patient 2 was a 20-year-old collegiate basketball player, who already had femoral head cyst formation around the S46

fovea, and acetabular cartilage delamination. However, he developed heterotopic ossification (Brooker grade 2) around the reflected head of the rectus femoris, which limited hip flexion to 90°. He reported substantial improvement in his symptoms, which he believes would have been even better if it were not for the ectopic bone formation. The patient has been reluctant to have the heterotopic os-


Costa Rocha et al

A

B

C

D

E

F

sification and trochanteric screws removed due to professional obligations (Fig. 2). Patient 3 is a 42-year-old teacher with currently “inactive” multiple sclerosis who presented with three years of chronic hip pain. A hip arthroscopy one year prior did not pro-

Fig. 1 - A) Preoperative AP pelvis ra diograph of patient 1 showing coxa profunda and severe rim ossification leading to a negatively tilted acetabu lar roof; B) MR arthrogram revealing a rim ossification, acceptable articular cartilage, but a large anterior wall cyst; C) Intraoperative photograph after rim trimming and anchor placement, before labral reconstruction; note en larged acetabular fossa with small weight bearing zone; D) Photograph of ossified tissue and from the acetabu lar rim; E) Intraoperative photo after complete labral reconstruction with hamstring allograft; F) AP Pelvis radio graph two years after surgery, still with no radiographic evidence of arthrosis.

vide any relief. Past surgical history included a high tibial osteotomy, followed by a total knee replacement on the contralateral side since the conservative approach did not improve symptoms. Her radiographs showed a small posterior wall osteophyte inferiorly, but MRA showed chondral


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A

Fig. 2 - A) AP hip radiograph from pa tient 2 showing protrusio; B) MR arthro gram showing global overcoverage, ossified anterior acetabular rim, a de formed femoral head and a cyst in the femoral head. Note that the acetabular coverage extends far beyond the equa tor of the femoral head; C) intraop erative photograph showing the bony overgrowth of the superior acetabular rim; D) intraoperative photograph of acetabulum after debridement of im pinging acetabular rim; the enlarged acetabular fossa leaves little room for articular cartilage; E) intraoperative photograph after labral reconstruc tion; F) six month follow-up radiograph showing a well preserved joint space and no osteophytes but heterotopic os sification in the vicinity of the indirect head of the rectus femoris. The HO was most likely initiated due to the disloca tion of the hip required for intraarticular treatment.

B

D

C

F

E

surfaces with minimal wear. The patient had the trochanteric screws removed for continued pain. An MRI one year S48

after surgical dislocation showed the graft was intact and good cartilage status. Because of chronic lateral hip pain,


Costa Rocha et al

B

A

Fig. 3 - A) AP pelvis radiograph of patient 3 before surgical dislocation; B) AP pelvis radiograph one year after surgery showing no radio graphic evidence of arthrosis.

the patient underwent revision surgery of the peritrochanteric space. A fascial defect in the iliotibial band and a large trochanteric bursa herniation were found and corrected. Now, two years after labral reconstruction, the patient reports less groin and trochanteric pain, although she is not completely satisfied with the result (Fig. 3). Patient 4 was a 21-year-old nurse with severe hip pain and limited reduced range of motion that significantly affected her daily activities. In addition to acetabular protrusion, pelvic-trochanteric impingement from coxa vara and a short femoral neck was evident during surgery. Therefore, a relative neck lengthening was performed concurrently with rim trimming and labral reconstruction. Her initial postoperative course was unremarkable, and she received low molecular weight heparin for DVT prophylaxis. Two weeks after surgery the patient developed a pulmonary embolism, but has recovered completely without consequence. After 3 months the patient is very satisfied with her result and has resumed full activities of daily living (Fig. 4).

DISCUSSION This small series of rare cases with severe pincer FAI and advanced labral degeneration were treated with acetabular rim trimming and labral reconstruction through a surgical dislocation approach. Impaction pincer damage to the labrum commonly results in rim ossification and accelerated joint degeneration (14). While arthroscopic treatments have

been suggested (21), only open surgical dislocation can provide exposure to the entire acetabular rim, in particular the posterior region (17). The purpose of this paper was to present the rationale, surgical technique, and preliminary results of open treatment of coxa profunda and protrusio with an incompetent labrum. To our knowledge, this is the first report of circumferential labral reconstruction using fresh frozen hamstring allografts. The surgical correction of coxa profunda and protrusio is challenging owing to complex pathomorphology. In addition to global overcoverage, the acetabular fossa is typically enlarged and positioned cranially. The articular cartilage is located more peripherally in these hips, which would leave a diminished cartilage stripe after aggressive rim trimming (5). Therefore, resection of the rim is limited, and often mild femoral head over-coverage must be accepted in order to preserve weight bearing cartilage. Additionally, acetabular osteotomy could be added to the procedure to optimise orientation of the weight bearing cartilage. In accordance with current literature, there are three options for surgical treatment labral injuries: debridement, repair, and reconstruction with autografts or allografts. The literature in biomechanics suggests that a functional labrum is required for hip joint homeostasis and labral resection should be avoided. Intra-articular hydrostatic fluid pressure has been found to be greater in the presence of a competent labrum. Furthermore, finite element analysis and cadaver studies have also shown labrum resec-


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A

Fig. 4 - A) AP hip radiograph of patient 4, showing protrusio (a high riding greater tro chanter coxa vara); B) immediate postop erative radiograph showing the degree of rim trimming with an almost horizontal acetabular roof, labral reconstruction (8 titanium anchors), and relative neck lengthening with trochanteric advancement; C) intraoperative photograph of labral reconstruction; D) hip radiograph taken three months after surgery showing healed os teotomy and preserved joint space, the femo ral head is not trapped as much in the acetabu lar socket as before surgery.

B

C

D

tion results in higher articular surface stresses, leading to increased frictional wear and eventual fatigue failure of collagen matrices (22-27). Labral preservation might be particularly important after rim trimming for global overcoverage. In this particular scenario, hips with a surgically reduced cartilagineous surface will benefit from the additional “stability” of an intact labrum (5). S50

In a recent review of five FAI studies, three showed a statistically significant benefit to labral repair as opposed to debridement alone (28). Espinosa et al, retrospectively reviewed 60 hips that underwent surgical hip dislocation for the treatment of femoro-acetabular impingement with acetabuloplasty and cheilectomy. In the first 25 hips the labrum was resected, and in the next 35 the labrum was


Costa Rocha et al

repaired to acetabular rim. At 2 years follow-up the repair group had significantly superior clinical and radiographic results (11). Other two studies compared patients that received arthroscopic labral repair with patients undergoing partial labrectomy, and also reported better results in the repair group (29, 30). Partial labrum reconstruction has been reported with good early outcomes with arthroscopic techniques using iliotibial band autograft (13, 14), and ligamentum teres autograft during open surgical dislocation (16). The average size of the ligamentum teres has been reported to be 25 mm in length and 15 mm width (31), too small for a complete circumferential labral reconstruction. For an acetabular radius of just 24 mm (the smallest in our series), a graft extending ¾ of the perimeter would need to be 113 mm in length (¾*2pr). Finally, in protrusion hip, due to the central impingement between the acetabular fossa and the femoral head, the ligamentum teres is frequently degenerated or even nonexistant making it unsuitable for transplantation. The semitendinous tendon allograft has the advantages of no donor-site morbidity, decreased operating time, predictable graft size and quality, easier and less painful rehabilitation. Although with current screening, processing and sterilization techniques the risk of disease transmission with allografts is extremely low, it should not be overlooked and was taken into consideration (32). Also, in our experience, allografts do not incite the same abundant fibroblastic response that is often seen in autograft reconstruction. The four patients in our series all have rare, complex hip deformities with an excessively deep acetabulum, but partially preserved articular cartilage. Three patients also had concurrent (most likely secondary) deformity of the proximal femur, which however, contributed to their injury patterns. While arthroscopic treatment of deep acetabuli has been suggested, there are multiple confounding factors arguing against this approach. Firstly, hips with global overcoverage are difficult to sublux, requiring excessive traction. In our patient with heterotopic ossification, even the more delicate dislocation maneuver during surgical dislocation may have inflicted trauma on the surround soft tissues. Secondly, surgical dislocation provides superior access to the anterior-inferior, and posterior-inferior joint for rim resection. As with any procedure, open or arthroscopic, surgical technique is paramount and there is potential for complications. In patient 2 with heterotopic ossification, we theorise that the force required to dislocate the hip during surgery may

have imparted trauma to the surround soft tissue. Unfortunately for a hip that his “captured” by acetabular overcoverage, we do not use any special distraction techniques to avoid this problem. The patient reports that the surgery “helped,” but would have “helped a lot” if he had improved flexion. Patient 4 had the most serious complication in a pulmonary embolus. The patient did not have known risk factors including family history, smoking, or oral contraceptive medication. At the time of PE, she was feeling well and ambulating independently with crutches. At last follow-up (3 months) she was completely satisfied with the clinical result and had no residual problems from the complication, except for her 12 months of oral anticoagulation therapy and use of compressive stockings. For the first patient the decision for labral reconstruction was made during surgery. In this case after rim trimming and initial labral repair, suction seal was inadequate because of absent labral tissue. After labral reconstruction, the suction seal was evident by a clear popping sound during dislocation and reduction of the femoral head (video can be provided). The second and the fourth patients were just 20 and 21 years old with protrusio acetabuli, and moderate cartilage wear. Clearly in this age group hip preservation surgery is preferable to arthroplasty options. Resecting the impinging bone and reconstructing the labrum best reestablished normal hip biomechanics, with the goal of improving cartilage health and decreasing shear forces. The third patient had the most difficult postoperative course. For her, the decision to perform labrum reconstruction was based on the appearance of normal articular cartilage during prior arthroscopy and on subsequent MRA. Neuromuscular symptoms from multiple sclerosis, as well as adverse effects from chronic immunomodulator medication also make joint replacement a less desirable option. At last follow-up the lateral sided hip pain was significantly improved after revision surgery, and her original groin pain was partially resolved. Interestingly, this patient with the lowest outcome scores continued to have Tonnis 0 radiographs and no significant findings on her MR arthrography. This study has obvious limitations: we report on a case series of only four patients at short-term follow-up. The patients in this series all had mild to moderate articular cartilage degeneration at the time of surgery that may compromise long-term results. Now that pincer FAI is being recognised earlier in the disease process, we hope to treat and report on larger numbers of patients in the future.


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The improvement of pain and function in our patients cannot be attributed to the labral reconstruction alone, and is also related to bony corrections performed for pincer FAI. However, we believe that, in light of experimental and clinical data, labral reconstruction may allow better restoration of hip biomechanics, ensuring longer cartilage life and therefore longer viability of the joint.

Acknowledgements

Conflict of interest: With respect to the presented work, there has been no financial gain brought to the Authors or to his/her families, business partners, or employers by direct or indirect commission; stock ownership or options in manufacturing company; involvement in any for-profit or not-for-profit corporation where the Author or his/ her family is a director or recipient of a grant, including consultant and travel costs reimbursement.

Financial support: There were no outside sources of funding for this study.

Address for correspondence: Michael Leunig, MD Department of Orthopaedic Surgery Hip Service Schulthess Klinik Lengghalde 2 8008 Zürich, Switzerland [email protected]

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Circumferential Labral Reconstruction Using the Knotless Pull-Through Technique-Surgical Technique.

Arthroscopic Technique for Acetabular Labral Reconstruction Using Iliotibial Band Autograft.

Arthroscopic Labral Reconstruction of the Hip Using Iliotibial Band Allograft and Front-to-Back Fixation Technique.

Arthroscopic Labral Reconstruction of the Hip Using Semitendinosus Allograft.

Arthroscopic Acetabular Labral Reconstruction with Fascia Lata Allograft: Clinical Outcomes at Minimum One-Year Follow-Up.

Labral Gracilis Tendon Allograft Reconstruction and Cartilage Regeneration Scaffold for an Uncontained Acetabular Cartilage Defect of the Hip.

Surgical management of acetabular fractures: a case series.

All-Arthroscopic Coracoclavicular Ligament Reconstruction Surgical Technique Using a Semitendinosus Allograft and Tenodesis Screws.

Arthroscopic-Assisted Acromioclavicular Joint Reconstruction Using the TightRope Device With Allograft Augmentation: Surgical Technique.

Superior Capsule Reconstruction Technique Using an Acellular Dermal Allograft.

Allograft reconstruction of peroneus longus and brevis tendons tears arising from a single muscular belly. Case report and surgical technique.

The value of bulk femoral head allograft in acetabular reconstruction using Kerboull-type plate.

Reconstruction and rehabilitation of severe mandibular atrophy using distraction osteogenesis technique: a case report.

Arthroscopic technique for chondrolabral capsular preservation during labral repair and acetabular osteoplasty.

Scapular allograft reconstruction after total scapulectomy: surgical technique and functional results.

Iliac crest allograft glenoid reconstruction for recurrent anterior shoulder instability in athletes: Surgical technique and results.

Sensory outcomes after reconstruction of lingual and inferior alveolar nerve discontinuities using processed nerve allograft--a case series.

Surgical reconstruction of partial circumferential esophageal defect in the dog.

Arthroscopic labral repair of the hip, using a through-labral double-stranded single-pass suture technique.

Repair of Proximal Hamstring Tears: A Surgical Technique.

Surgical treatment of congenital patellar dislocation in skeletally mature patients: surgical technique and case series.

Acetabular rim length: an anatomical study to determine reasonable graft sizes for labral reconstruction.

Minimally invasive medial patellofemoral ligament reconstruction with fascia lata allograft: surgical technique.

Arthroscopic labral reconstruction of the hip using local capsular autograft.