Labral augmentation with ligamentum capitis femoris: presentation of a new technique and preliminary results

Labral augmentation with ligamentum capitis femoris: presentation of a new technique and... Journal of Hip Preservation Surgery Vol. 5, No. 1, pp. 47–53 doi: 10.1093/jhps/hnx049 Advance Access Publication 16 January 2018 Research article Labral augmentation with ligamentum capitis femoris: presentation of a new technique and preliminary results Jan Weidner*, Michael Wyatt and Martin Beck Clinic for Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Spitalstrasse, 6000 Luzern 16, Switzerland *Correspondence to: J. Weidner. E-mail: jan.weidner@luks.ch Submitted 31 May 2017; revised version accepted 19 December 2017 ABSTRACT Preservation of an intact labrum and reconstruction of a deficient or worn acetabular labrum are accepted techniques in modern hip surgery. If the remaining labrum is very thin, its intact tip can be preserved and its vol- ume restored with a ligamentum teres graft. Technique and preliminary results of this augmentation technique are presented. Labral augmentation was performed in 16 hips (11 rights) in 16 patients (7 males, mean age 29 years) during surgical dislocation for treatment of femoroacetabular impingement. The acetabular index, lateral center edge angle, asphericity angle and acetabular retroversion index were determined on preoperative X-rays and magnetic resonance imaging. The pre- and postoperative Merle d’Aubigne´ and Postel score (MdA) was cal- culated and the Oxford Hip Score (OHS) obtained after 1 year. There were seven Grade 1 and nine Grade 0 hips (To¨nnis classification). Mean lateral center edge was 29 . The mean acetabular index was 1.85 . Mean asphericity angle was 62.5 . Mean acetabular retroversion index was 23.4%. Mean MdA improved from 14.5 preoperatively to 17 at 1 year (P< 0.0001). Mean OHS after 1 year was 42. Previous surgery was a risk factor for inferior results: OHS was 44.5 in hips without versus 26 in hips with previous surgery. Mean MdA improved from 15 to 17.5 in patients without previous surgery versus 14 to 16 for the group with previous surgery. Augmentation of the labrum using ligamentum teres shows good clinical results after 1 year. Patients with previous hip surgery had inferior results. is nowadays recommended by most authors in order to INTRODUCTION preserve its function as a stabilizer of the hip joint [4]. The acetabular labrum enlarges the acetabular surface and Recent studies focussing on the suction seal effect of the la- provides additional stability to the hip joint [1]. While ani- brum underline the importance of an intact labrum regard- mal studies suggested that regeneration of the labrum after ing intraarticular fluid pressurization. Pressurization of the partial excision to the bone is possible, there seems to be interstitial fluid within the cartilage protects the cartilage no such potential for regeneration in humans [2]. In joint from load, while pressurization of the intraarticular fluid preserving hip surgery, the labrum is usually reattached to decreases friction between the acetabulum and the femoral the acetabulum with bone anchors when it is torn or head [5–7]. It has been shown that labral tears lead to a re- degenerated [3]. If the remaining labrum is too thin or ex- duction in fluid pressurization in the hip joint. The group tensively damaged, treatment options include resection or of Philippon et al. demonstrated that intra-articular fluid reconstruction with grafts. Most techniques for labral re- pressure is increased by labral repair while it is drastically construction use auto- or allografts to replace the original reduced after partial or complete labral resection [8]. In an labrum. Different studies report good clinical outcomes re- experimental setting, reconstruction of the labrum with garding hip function, patient satisfaction and reduction of iliotibial band autograft lead to an intra-articular fluid pain after labral reconstruction. While long-term results are pressurization similar to a normal hip with an intact still missing, preservation or reconstruction of the labrum V C The Author(s) 2018. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by- nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jhps/article-abstract/5/1/47/4812017 by Ed 'DeepDyve' Gillespie user on 16 March 2018 48  J. Weidner et al. labrum [9, 10]. The same can be expected when restor- decision whether labral augmentation was necessary or not ation of the suction seal can be achieved by labral augmen- was made intraoperatively. Routine preoperative diagnos- tation using the ligamentum capitis femoris. tics included an ap pelvic X-ray, lateral cross-table view of There are concerns that with segmental reconstruction of the hip and MR arthrography. The joint degeneration was the labrum the hoop stress cannot be restored because of graded according to the To¨nnis classification for osteoarth- the interruption of the circumferential fibres. The rationale ritis. The acetabular index (AI), the lateral center edge of this technique is that with the preservation of the intact (LCE) angle, and the acetabular retroversion index (ARI) tip of the labrum the hoop stress capability is maintained were measured on the conventional radiographs preopera- and the sealing effect of the labrum is improved by adding tively [13]. The preoperative asphericity angle (AA) was volume with a graft of the ligamentum teres between the measured on the radial sequences of the MR arthrography bony rim and the preserved part of the labrum [11]. We pre- and on the cross-table view conventional radiograph. sent the technique and the preliminary results after 1 year. Measurement of the AI, LCE and AA was repeated on the postoperative X-rays that included an ap pelvic view and a MATERIALS AND METHODS lateral cross-table view of the hip. The type of impinge- From April 2013 to December 2015, we performed labral ment was classified as pincer, cam or combined. An aspher- augmentation with ligamentum teres in 16 hips (11 rights) icity angle >55 was considered a cam-deformity. A pincer in 16 patients (7 males, mean age 29 years) during surgical impingement was defined by an LCE >35 or a retrover- dislocation for the treatment of femoroacetabular impinge- sion index of more than 33%. Intraoperatively, the type of ment (FAI). Indication for surgery was symptomatic FAI acetabular damage and labral damage was graded according syndrome with groin pain and typical radiographic findings to Beck (Tables I and II)[14]. as it has been stated in the Warwick Agreement on FAI Radiographic and clinical follow-up was done at 6 weeks syndrome [12]. The indication for labral augmentation and 1 year postoperatively. The Merle d’Aubigne´and Postel was a thin (1–2 mm) labrum which seemed to provide an score (MdA) was calculated preoperatively and at the 1 year insufficient seal without additional augmentation. The final follow-up. A score of 15–18 indicates a good to excellent Table I. Beck classification of cartilage damage Beck classification of cartilage damage Grade Description Criteria 0 Normal Macroscopically sound cartilage 1 Malacia Roughening of surface, fibrillation 2 Debonding Loss of fixation to subchondral bone, macroscopically sound cartilage; carpet phenomenon 3 Cleavage Loss of fixation to subchondral bone, frayed edge, thinning of the cartilage, flap 4 Defect Full-thickness defect Table II. Beck classification of labral damage Beck classification of labral damage Grade Description Criteria 0 Normal Macroscopically sound labrum 1 Degeneration Thinning or localized hypertrophy, fraying, discoloration 2 Full-thickness tear Complete avulsion from the acetabular rim 3 Detachment Separation between acetabular and labral cartilage, preserved attachment to bone 4 Ossification Osseous metaplasia, localized or circumferential Downloaded from https://academic.oup.com/jhps/article-abstract/5/1/47/4812017 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Labral augmentation with ligamentum capitis femoris  49 result, 12–14 a fair result and less than 12 points a poor re- is then sharply detached from the acetabulum and trim- sult [15]. The Oxford Hip Score (OHS) was obtained at the ming of the bony acetabulum is performed as needed. The 1 year follow-up with a score higher than 40 indicating an ac- ligamentum teres graft is sutured in between the acetabu- ceptable result [16]. One patient developed neurologic prob- lum and the remaining labrum using bone anchors lems related to a neurogenic tumor during the follow-up (Fig. 1). Detachment of the labrum and augmentation with period. In this patient, the OHS was not acquired. the ligamentum teres graft is shown in the intraoperative photographs (Figs 2–5). After correction of the offset on the femur, the femoral head is reduced and the hip tested Surgical technique for stability and impingement-free motion. If the suction In all cases, surgery was performed by the same surgeon seal is restored after the labral augmentation, a characteris- (M.B.). After performing a surgical dislocation with the tic suction seal sound can be heard when trying to dislo- technique of Ganz et al. [17], the ligamentum teres is re- cate the hip again. At the end of surgery, the joint capsule sected from the fovea of the femoral head. Adherent fatty is closed loosely and the greater trochanter reattached with tissue and the synovial cover are removed from the liga- two 3.5 mm screws. There were no intraoperative ment. It is then cut longitudinally in the center leaving a small hinge in the middle, yielding a graft twice as long as the original ligament with a width of 4–5 mm. The labrum Fig. 1. The degenerated labrum is detached from the acetabu- lum. Rim trimming is performed if necessary. The labrum is then augmented with the ligamentum teres graft and reattached with bone anchors. Fig. 3. Intraoperative photograph. The ligamentum teres graft is sutured between the labrum and the acetabular rim. Fig. 4. Intraoperative photograph with the ligamentum teres Fig. 2. Intraoperative photograph showing the detached labrum. graft in its final position. Downloaded from https://academic.oup.com/jhps/article-abstract/5/1/47/4812017 by Ed 'DeepDyve' Gillespie user on 16 March 2018 50  J. Weidner et al. AA was 62.5 (SD 12.4, range 52–106). The mean ARI was 23.4% (SD 10.8, range 6.4–40.0). The MdA score im- proved from mean 14.5 (SD 0.93, range 13–16) preopera- tively to 17 (SD 1.75, range 11–18) at 1 year (P< 0.0001) (Fig. 6). The main improvement in the MdA score was due to a reduction of pain with good walking ability and hip ROM pre- and postoperatively. The mean OHS after 1 year was 42 (SD 9.1, range 17–48). Previous surgery was a risk factor for inferior results. Hips without previous surgery had a mean OHS of 44.5 (SD 6.6, range 29–48) versus 26 (SD 10.3, range 17–42) in the hips with previous surgery at the 1 year follow-up. Regarding the MdA score, the mean score improved from 15 (SD 1.0, range 13–16) preoperatively to 17.5 (SD 0.8, range 17–18) in Group 1 without previous surgery versus 14 (SD 0.7, range 13–15) to 16 (SD 2.4, range 11–17) for Group 2 with previous surgery (Fig. 7). Whether this is Fig. 5. Intraoperative photograph after reduction of the femoral statistically significant was not calculated because of the head. small sample size (four hips) with previous surgery. complications. All trochanters healed during the follow-up DISCUSSION period. The postoperative rehabilitation protocol included The principle findings of this study are (i) that labral aug- partial weight bearing with 15 kg for 4 weeks and increas- mentation with ligamentum capitis femoris can adequately ing weight bearing during the following 2 weeks as toler- restore the labrum and its sealing function and (ii) that ated. The range of motion was limited to 90 of flexion, this technique yields good clinical results after 1 year. Both 20 internal and external rotation for the first 4 weeks and arthroscopic and open impingement surgery aim to treat gradually increased thereafter. A continuous passive mo- the underlying pathology of patients with FAI. Besides cor- tion machine was applied from the first day after surgery recting the cam deformity on the femoral neck and trim- and the hip was regularly mobilized on a stationary bike ming the bony acetabulum for correction of the pincer after discharge from the hospital during the first 6 weeks. deformity, the labral pathology has to be addressed ad- Three patients had screw removal at the greater trochanter. equately. Labral degeneration occurs at different stages and One patient had an additional hip arthroscopy for removal can be observed more often in the pincer and combined of intraarticular adhesions 1 year after surgery. After the se- impingement population than in patients with pure cam cond surgery, the residual pain improved, but not com- impingement [18]. A number of recent studies have pletely. In none of the hips any signs of disturbed wound focused on the suction seal effect of the labrum. It is healing or infection were noted. hypothesized that an intact labrum, besides giving primary stability to the hip adds to additional stability through this RESULTS suction seal effect. When distraction forces act upon the Patients’ demographic data and the results of the measure- hip joint, a negative fluid pressure in the articular fluid is ments and clinical sores are summarized in Table III.Of created, thus giving additional stability between the fem- the 16 hips included in this study, 10 hips had a cam oral head and the acetabulum. This negative fluid pressur- morphology with an asphericity angle>55 . One hip only ization can only function when the seal that is created by showed characteristics of a pincer impingement with the the labrum is intact [9]. It has been shown that the integ- LCE>35 and ARI>33% and five hips were combined rity of the labral seal can be restored by means of labral impingement hips. There were seven Grade 1 and nine reconstruction [5, 8, 9]. For this, open and arthroscopic Grade 0 hips according to the To¨nnis classification for techniques have been advocated, most of them using a osteoarthritis. Four hips had previous surgery (three hip graft to reconstruct the deficient labrum. arthroscopy, one had two previous hip arthroscopies and a While labral reconstruction replaces a section of the dam- periacetabular osteotomy). aged labrum in its full thickness, the labral augmentation The mean LCE was 29 (SD 4.9, range 25–39). The technique preserves part of the original labrum, which was mean AI was 1.85 (SD 3.9, range 0.5 to 9.9). The mean shown previously to be intact [11]. Thetip of thedamaged Downloaded from https://academic.oup.com/jhps/article-abstract/5/1/47/4812017 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Labral augmentation with ligamentum capitis femoris  51 Downloaded from https://academic.oup.com/jhps/article-abstract/5/1/47/4812017 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Table III. Patient demographics and results of radiographic measurements and clinical scores Patient Age Gender Side FAI To¨nnis Cartilage Labrum AI ( ) LCE ARI AA pre AA pre AI LCE AA post MdA MdA OHS Previous grade —Beck —Beck ( ) (%) (MRI) (X-ray) postop post (X-ray) pre post post surgeries ( ) ( ) ( ) ( ) ( ) 1 27 M Right Cam 0 0 1 10 26 31 62 40 10 24 37 14 17 42 Arthroscopy 2 18 F Right Mixed 0 0 4 1 28 38 68 43 0 25 42 15 18 35 0 3 40 F Right Cam 1 3 3 1 31 14 73 43 4 27 43 13 11 17 Arthroscopy 4 35 M Left Cam 1 3 4 5 26 15 65 55 9 23 51 16 18 45 0 5 23 M Left Cam 1 3 1 8 25 25 80 67 12 23 47 15 17 Arthroscopy 6 30 M Right Mixed 1 0 1 1 35 6 59 62 1 33 42 13 18 44 0 7 16 F Right Mixed 0 0 1 1 42 36 65 40 3 34 40 15 18 48 0 8 19 F Right Pincer 0 0 1 3 39 32 52 46 4 25 40 14 15 26 Arthroscopy, PAO 9 29 F Left Cam 0 0 2 5 29 20 61 50 7 28 50 14 15 29 0 10 35 F Right Cam 0 3 1 2 29 22 62 59 4 27 42 15 17 47 0 11 34 M Right Cam 1 3 4 2 27 30 63 55 2 26 46 16 18 47 0 12 26 M Right Mixed 1 3 1 3 36 14 106 56 1 28 50 15 17 46 0 13 36 F Left Cam 0 0 1 9 29 35 56 53 9 23 42 14 18 48 0 14 26 F Right Mixed 1 0 1 1 36 40 61 54 3 28 45 13 17 36 0 15 31 F Right Cam 0 0 1 0 33 5 55 51 2 27 44 15 17 34 0 16 31 M Left Cam 0 3 1 7 28 20 74 58 8 26 45 14 17 34 0 MRI, magnetic resonance imaging. OHS not acquired in one patient due to tumor-related neurologic problems newly developed during the follow up period. 52  J. Weidner et al. Fig. 6. Boxplot of the pre- and postoperative Merle d’Aubigne´ and Postel score. Fig. 7. Boxplot diagram comparing the pre- and postoperative MdA score for Group 1 (with previous surgery) and Group 2 (no previ- ous surgery). labrum is preserved and augmented by a graft. The rationale dislocating the hip again after performing the augmentation. of the technique is (i) to maintain the hoop stress capability A characteristic vacuum sound is heard if the seal is restored by preserving the intact tip of the labrum and (ii) to improve correctly. This gives additional confirmation of a technically the sealing effect of the labrum by adding volume to it. This good reconstruction. The open technique also allows to re- is achieved by placing a ligamentum teres graft between the adjust graft and suture placement in order to achieve a func- bony rim and the preserved part of the labrum. The ligamen- tional reconstruction. tum teres is an ideal graft for this as it can easily be harvested We observed inferior results regarding the clinical out- during surgical hip dislocation and has no additional morbid- comes in the patient group with previous hip surgery. In all ity. An alternative source for a graft that can be used in the patients who had hip arthroscopies with cam resection and same way is the fascia lata. With the open approach, the res- labral refixation before, we saw a variable degree of intraar- toration of the suction seal effect can be easily controlled by ticular adhesions. In two cases, the offset correction was Downloaded from https://academic.oup.com/jhps/article-abstract/5/1/47/4812017 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Labral augmentation with ligamentum capitis femoris  53 not carried out completely by the arthroscopic procedure. REFERENCES In one patient, the magnetic resonance imaging revealed 1. Bsat S, Frei H, Beaule´ PE. The acetabular labrum. Bone Joint J extensive intraarticular adhesions and a recurrence of the 2016; 98-B: 730–5. offset pathology as well as additional osteophytes at the 2. Miozzari HH, Celia M, Clark JM et al. No regeneration of the femoral head–neck junction 1 year after hip arthroscopy. human acetabular labrum after excision to bone. Clin Orthop Relat Res 2015; 473: 1349–57. In the same patient, the actabular labrum was clumsy with 3. Espinosa N, Beck M, Rothenfluh DA et al. Treatment of femoro- an insufficient suction seal. After open surgery with labral acetabular impingement: preliminary results of labral refixation. augmentation, the residual pain resolved to some degree J Bone Joint Surg Am 2007; 89: 36–53. and clinical scores improved. However, we suspect that the 4. Haddad B, Konan S, Haddad FS. Debridement versus re- inferior results in these four patients might be related to attachment of acetabular labral tears: a review of the literature the formation of intraarticular adhesions and to the incom- and qualitative analysis. Bone Joint J 2014; 96-B: 24–30. plete correction of the deformity which in turn led to a 5. Cadet ER, Chan AK, Vorys GC et al. Investigation of the preser- vation of the fluid seal effect in the repaired, partially resected, persistence of FAI symptoms and progression of cartilage and reconstructed acetabular labrum in a cadaveric hip model. damage. 50% of patients in this group had OA Grade 1, Am J Sports Med 2012; 40: 2218. while only 42% had Grade 1 OA in the group with no pre- 6. Ferguson SJ, Bryant JT, Ganz R et al. An in vitro investigation of vious surgery. Obviously, the patients with previous sur- the acetabular labral seal in hip joint mechanics. J Biomech 2003; geries had a longer history of hip pain before the labral 36: 171–8. augmentation was performed. In this context, it can be dis- 7. Ferguson SJ, Bryant JT, Ganz R et al. The acetabular labrum seal: cussed if a certain degree of chronification of pain could a proroelastic finite element model. Clin Biomech 2000; 15: 463–8. add to the inferior results in this group. 8. Nepple JJ, Philippon MJ, Campbell KJ et al. The hip fluid seal - Part II: The effect of an acetabular labral tear, repair, resection, Our results regarding the clinical scores are comparable and reconstruction on hip stability to distraction. Knee Surg Sports to the clinical outcome reported in a previous study that Traumatol Arthrosc 2014; 22: 730–6. used the ligamentum capitis femoris for labral reconstruc- 9. Philippon MJ, Nepple JJ, Campbell KJ et al. The hip fluid seal - tion instead of labral augmentation [19]. Part I: The effect of an acetabular labral tear, repair, resection, Limitations of the study are due to its retrospective na- and reconstruction on hip fluid pressurization. Knee Surg Sports ture. The study group consists of a relatively small number Traumatol Arthrosc 2014; 22: 722–9. of patients and has a limited follow-up period. We did not in- 10. Philippon MJ, Briggs KK, Hay CJ et al. Arthroscopic labral recon- struction in the hip using iliotibial band autograft: technique and clude a control group. On one hand, it would be difficult to early outcomes. Arthroscopy 2010; 26: 750–6. compare the results of our study group to another patient 11. Ito K, Leunig M, Ganz R. Histopathologic features of the acetabu- group requiring surgical hip dislocation. Also, we did not aim lar labrum in femoroacetabular impingement. Clin Orthop Relat to compare our results to other techniques. The purpose of Res 2004; 429: 262–71. this study was to present the technique of labral augmenta- 12. Griffin DR, Dickenson EJ, O’Donnell J et al. The Warwick agree- tion using the ligamentum teres and to report on our initial ment on femoroacetabular impingement syndrome (FAI syn- results after 1 year. The results are based on the adequate drome): an international consensus statement. Br J Sports Med 2016; 50: 1169–76. restoration of the suction seal which is directly tested intrao- 13. Beck M, Kalhor M, Leunig M et al. Hip morphology influences peratively and on clinical results. However, there are no ob- the pattern of damage to the acetabular cartilage. J Bone Joint Surg jective tests to report on the effect of the labral Br 2005; 87: 1012–8. augmentation on the restoration of the suction seal. 14. Tannast M, Siebenrock KA, Anderson SE. Femoroacetabular im- The intraoperative findings after performing labral augmen- pingement: radiographic diagnosis - what the radiologist should tation with the technique described demonstrated an adequate know. AJR 2007; 188: 1540–52. restoration of the suction seal. The overall clinical results after 15. D’Aubigne´ RM, Postel M. Functional results of hip arthroplasty a 1 year follow-up were good. When compared with patients with acrylic prosthesis. J Bone Joint Surg Am 1954; 36:451–75. 16. Murray DW, Fitzpatrick R, Rogers K et al. The use of the Oxford without previous surgery, patients who had undergone failed hip and knee scores. J Bone Joint Surg Br 2007; 89: 1010–4. joint preserving hip surgery before had inferior results. 17. Ganz R, Gill TJ, Gautier E et al. Surgical dislocation of the adult hip. J Bone Joint Surg Br 2001; 83: 1119–24. 18. Beck M, Leunig M, Parvizi J et al. Anterior femoroacetabular im- ACKNOWLEDGEMENT pingement: mid- term results of surgical treatment. Clin Orthop We thank K. Oberli for creation of the line drawings. 2004; 418: 67–73. 19. Camenzind RS, Steurer-Dober I, Beck M. Clinical and radio- CONFLICT OF INTEREST STATEMENT graphical results of labral reconstruction. J Hip Preserv Surg; 2: None declared. 401–9. Downloaded from https://academic.oup.com/jhps/article-abstract/5/1/47/4812017 by Ed 'DeepDyve' Gillespie user on 16 March 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Hip Preservation Surgery Oxford University Press

Labral augmentation with ligamentum capitis femoris: presentation of a new technique and preliminary results

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Journal of Hip Preservation Surgery Vol. 5, No. 1, pp. 47–53 doi: 10.1093/jhps/hnx049 Advance Access Publication 16 January 2018 Research article Labral augmentation with ligamentum capitis femoris: presentation of a new technique and preliminary results Jan Weidner*, Michael Wyatt and Martin Beck Clinic for Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Spitalstrasse, 6000 Luzern 16, Switzerland *Correspondence to: J. Weidner. E-mail: jan.weidner@luks.ch Submitted 31 May 2017; revised version accepted 19 December 2017 ABSTRACT Preservation of an intact labrum and reconstruction of a deficient or worn acetabular labrum are accepted techniques in modern hip surgery. If the remaining labrum is very thin, its intact tip can be preserved and its vol- ume restored with a ligamentum teres graft. Technique and preliminary results of this augmentation technique are presented. Labral augmentation was performed in 16 hips (11 rights) in 16 patients (7 males, mean age 29 years) during surgical dislocation for treatment of femoroacetabular impingement. The acetabular index, lateral center edge angle, asphericity angle and acetabular retroversion index were determined on preoperative X-rays and magnetic resonance imaging. The pre- and postoperative Merle d’Aubigne´ and Postel score (MdA) was cal- culated and the Oxford Hip Score (OHS) obtained after 1 year. There were seven Grade 1 and nine Grade 0 hips (To¨nnis classification). Mean lateral center edge was 29 . The mean acetabular index was 1.85 . Mean asphericity angle was 62.5 . Mean acetabular retroversion index was 23.4%. Mean MdA improved from 14.5 preoperatively to 17 at 1 year (P< 0.0001). Mean OHS after 1 year was 42. Previous surgery was a risk factor for inferior results: OHS was 44.5 in hips without versus 26 in hips with previous surgery. Mean MdA improved from 15 to 17.5 in patients without previous surgery versus 14 to 16 for the group with previous surgery. Augmentation of the labrum using ligamentum teres shows good clinical results after 1 year. Patients with previous hip surgery had inferior results. is nowadays recommended by most authors in order to INTRODUCTION preserve its function as a stabilizer of the hip joint [4]. The acetabular labrum enlarges the acetabular surface and Recent studies focussing on the suction seal effect of the la- provides additional stability to the hip joint [1]. While ani- brum underline the importance of an intact labrum regard- mal studies suggested that regeneration of the labrum after ing intraarticular fluid pressurization. Pressurization of the partial excision to the bone is possible, there seems to be interstitial fluid within the cartilage protects the cartilage no such potential for regeneration in humans [2]. In joint from load, while pressurization of the intraarticular fluid preserving hip surgery, the labrum is usually reattached to decreases friction between the acetabulum and the femoral the acetabulum with bone anchors when it is torn or head [5–7]. It has been shown that labral tears lead to a re- degenerated [3]. If the remaining labrum is too thin or ex- duction in fluid pressurization in the hip joint. The group tensively damaged, treatment options include resection or of Philippon et al. demonstrated that intra-articular fluid reconstruction with grafts. Most techniques for labral re- pressure is increased by labral repair while it is drastically construction use auto- or allografts to replace the original reduced after partial or complete labral resection [8]. In an labrum. Different studies report good clinical outcomes re- experimental setting, reconstruction of the labrum with garding hip function, patient satisfaction and reduction of iliotibial band autograft lead to an intra-articular fluid pain after labral reconstruction. While long-term results are pressurization similar to a normal hip with an intact still missing, preservation or reconstruction of the labrum V C The Author(s) 2018. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by- nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jhps/article-abstract/5/1/47/4812017 by Ed 'DeepDyve' Gillespie user on 16 March 2018 48  J. Weidner et al. labrum [9, 10]. The same can be expected when restor- decision whether labral augmentation was necessary or not ation of the suction seal can be achieved by labral augmen- was made intraoperatively. Routine preoperative diagnos- tation using the ligamentum capitis femoris. tics included an ap pelvic X-ray, lateral cross-table view of There are concerns that with segmental reconstruction of the hip and MR arthrography. The joint degeneration was the labrum the hoop stress cannot be restored because of graded according to the To¨nnis classification for osteoarth- the interruption of the circumferential fibres. The rationale ritis. The acetabular index (AI), the lateral center edge of this technique is that with the preservation of the intact (LCE) angle, and the acetabular retroversion index (ARI) tip of the labrum the hoop stress capability is maintained were measured on the conventional radiographs preopera- and the sealing effect of the labrum is improved by adding tively [13]. The preoperative asphericity angle (AA) was volume with a graft of the ligamentum teres between the measured on the radial sequences of the MR arthrography bony rim and the preserved part of the labrum [11]. We pre- and on the cross-table view conventional radiograph. sent the technique and the preliminary results after 1 year. Measurement of the AI, LCE and AA was repeated on the postoperative X-rays that included an ap pelvic view and a MATERIALS AND METHODS lateral cross-table view of the hip. The type of impinge- From April 2013 to December 2015, we performed labral ment was classified as pincer, cam or combined. An aspher- augmentation with ligamentum teres in 16 hips (11 rights) icity angle >55 was considered a cam-deformity. A pincer in 16 patients (7 males, mean age 29 years) during surgical impingement was defined by an LCE >35 or a retrover- dislocation for the treatment of femoroacetabular impinge- sion index of more than 33%. Intraoperatively, the type of ment (FAI). Indication for surgery was symptomatic FAI acetabular damage and labral damage was graded according syndrome with groin pain and typical radiographic findings to Beck (Tables I and II)[14]. as it has been stated in the Warwick Agreement on FAI Radiographic and clinical follow-up was done at 6 weeks syndrome [12]. The indication for labral augmentation and 1 year postoperatively. The Merle d’Aubigne´and Postel was a thin (1–2 mm) labrum which seemed to provide an score (MdA) was calculated preoperatively and at the 1 year insufficient seal without additional augmentation. The final follow-up. A score of 15–18 indicates a good to excellent Table I. Beck classification of cartilage damage Beck classification of cartilage damage Grade Description Criteria 0 Normal Macroscopically sound cartilage 1 Malacia Roughening of surface, fibrillation 2 Debonding Loss of fixation to subchondral bone, macroscopically sound cartilage; carpet phenomenon 3 Cleavage Loss of fixation to subchondral bone, frayed edge, thinning of the cartilage, flap 4 Defect Full-thickness defect Table II. Beck classification of labral damage Beck classification of labral damage Grade Description Criteria 0 Normal Macroscopically sound labrum 1 Degeneration Thinning or localized hypertrophy, fraying, discoloration 2 Full-thickness tear Complete avulsion from the acetabular rim 3 Detachment Separation between acetabular and labral cartilage, preserved attachment to bone 4 Ossification Osseous metaplasia, localized or circumferential Downloaded from https://academic.oup.com/jhps/article-abstract/5/1/47/4812017 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Labral augmentation with ligamentum capitis femoris  49 result, 12–14 a fair result and less than 12 points a poor re- is then sharply detached from the acetabulum and trim- sult [15]. The Oxford Hip Score (OHS) was obtained at the ming of the bony acetabulum is performed as needed. The 1 year follow-up with a score higher than 40 indicating an ac- ligamentum teres graft is sutured in between the acetabu- ceptable result [16]. One patient developed neurologic prob- lum and the remaining labrum using bone anchors lems related to a neurogenic tumor during the follow-up (Fig. 1). Detachment of the labrum and augmentation with period. In this patient, the OHS was not acquired. the ligamentum teres graft is shown in the intraoperative photographs (Figs 2–5). After correction of the offset on the femur, the femoral head is reduced and the hip tested Surgical technique for stability and impingement-free motion. If the suction In all cases, surgery was performed by the same surgeon seal is restored after the labral augmentation, a characteris- (M.B.). After performing a surgical dislocation with the tic suction seal sound can be heard when trying to dislo- technique of Ganz et al. [17], the ligamentum teres is re- cate the hip again. At the end of surgery, the joint capsule sected from the fovea of the femoral head. Adherent fatty is closed loosely and the greater trochanter reattached with tissue and the synovial cover are removed from the liga- two 3.5 mm screws. There were no intraoperative ment. It is then cut longitudinally in the center leaving a small hinge in the middle, yielding a graft twice as long as the original ligament with a width of 4–5 mm. The labrum Fig. 1. The degenerated labrum is detached from the acetabu- lum. Rim trimming is performed if necessary. The labrum is then augmented with the ligamentum teres graft and reattached with bone anchors. Fig. 3. Intraoperative photograph. The ligamentum teres graft is sutured between the labrum and the acetabular rim. Fig. 4. Intraoperative photograph with the ligamentum teres Fig. 2. Intraoperative photograph showing the detached labrum. graft in its final position. Downloaded from https://academic.oup.com/jhps/article-abstract/5/1/47/4812017 by Ed 'DeepDyve' Gillespie user on 16 March 2018 50  J. Weidner et al. AA was 62.5 (SD 12.4, range 52–106). The mean ARI was 23.4% (SD 10.8, range 6.4–40.0). The MdA score im- proved from mean 14.5 (SD 0.93, range 13–16) preopera- tively to 17 (SD 1.75, range 11–18) at 1 year (P< 0.0001) (Fig. 6). The main improvement in the MdA score was due to a reduction of pain with good walking ability and hip ROM pre- and postoperatively. The mean OHS after 1 year was 42 (SD 9.1, range 17–48). Previous surgery was a risk factor for inferior results. Hips without previous surgery had a mean OHS of 44.5 (SD 6.6, range 29–48) versus 26 (SD 10.3, range 17–42) in the hips with previous surgery at the 1 year follow-up. Regarding the MdA score, the mean score improved from 15 (SD 1.0, range 13–16) preoperatively to 17.5 (SD 0.8, range 17–18) in Group 1 without previous surgery versus 14 (SD 0.7, range 13–15) to 16 (SD 2.4, range 11–17) for Group 2 with previous surgery (Fig. 7). Whether this is Fig. 5. Intraoperative photograph after reduction of the femoral statistically significant was not calculated because of the head. small sample size (four hips) with previous surgery. complications. All trochanters healed during the follow-up DISCUSSION period. The postoperative rehabilitation protocol included The principle findings of this study are (i) that labral aug- partial weight bearing with 15 kg for 4 weeks and increas- mentation with ligamentum capitis femoris can adequately ing weight bearing during the following 2 weeks as toler- restore the labrum and its sealing function and (ii) that ated. The range of motion was limited to 90 of flexion, this technique yields good clinical results after 1 year. Both 20 internal and external rotation for the first 4 weeks and arthroscopic and open impingement surgery aim to treat gradually increased thereafter. A continuous passive mo- the underlying pathology of patients with FAI. Besides cor- tion machine was applied from the first day after surgery recting the cam deformity on the femoral neck and trim- and the hip was regularly mobilized on a stationary bike ming the bony acetabulum for correction of the pincer after discharge from the hospital during the first 6 weeks. deformity, the labral pathology has to be addressed ad- Three patients had screw removal at the greater trochanter. equately. Labral degeneration occurs at different stages and One patient had an additional hip arthroscopy for removal can be observed more often in the pincer and combined of intraarticular adhesions 1 year after surgery. After the se- impingement population than in patients with pure cam cond surgery, the residual pain improved, but not com- impingement [18]. A number of recent studies have pletely. In none of the hips any signs of disturbed wound focused on the suction seal effect of the labrum. It is healing or infection were noted. hypothesized that an intact labrum, besides giving primary stability to the hip adds to additional stability through this RESULTS suction seal effect. When distraction forces act upon the Patients’ demographic data and the results of the measure- hip joint, a negative fluid pressure in the articular fluid is ments and clinical sores are summarized in Table III.Of created, thus giving additional stability between the fem- the 16 hips included in this study, 10 hips had a cam oral head and the acetabulum. This negative fluid pressur- morphology with an asphericity angle>55 . One hip only ization can only function when the seal that is created by showed characteristics of a pincer impingement with the the labrum is intact [9]. It has been shown that the integ- LCE>35 and ARI>33% and five hips were combined rity of the labral seal can be restored by means of labral impingement hips. There were seven Grade 1 and nine reconstruction [5, 8, 9]. For this, open and arthroscopic Grade 0 hips according to the To¨nnis classification for techniques have been advocated, most of them using a osteoarthritis. Four hips had previous surgery (three hip graft to reconstruct the deficient labrum. arthroscopy, one had two previous hip arthroscopies and a While labral reconstruction replaces a section of the dam- periacetabular osteotomy). aged labrum in its full thickness, the labral augmentation The mean LCE was 29 (SD 4.9, range 25–39). The technique preserves part of the original labrum, which was mean AI was 1.85 (SD 3.9, range 0.5 to 9.9). The mean shown previously to be intact [11]. Thetip of thedamaged Downloaded from https://academic.oup.com/jhps/article-abstract/5/1/47/4812017 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Labral augmentation with ligamentum capitis femoris  51 Downloaded from https://academic.oup.com/jhps/article-abstract/5/1/47/4812017 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Table III. Patient demographics and results of radiographic measurements and clinical scores Patient Age Gender Side FAI To¨nnis Cartilage Labrum AI ( ) LCE ARI AA pre AA pre AI LCE AA post MdA MdA OHS Previous grade —Beck —Beck ( ) (%) (MRI) (X-ray) postop post (X-ray) pre post post surgeries ( ) ( ) ( ) ( ) ( ) 1 27 M Right Cam 0 0 1 10 26 31 62 40 10 24 37 14 17 42 Arthroscopy 2 18 F Right Mixed 0 0 4 1 28 38 68 43 0 25 42 15 18 35 0 3 40 F Right Cam 1 3 3 1 31 14 73 43 4 27 43 13 11 17 Arthroscopy 4 35 M Left Cam 1 3 4 5 26 15 65 55 9 23 51 16 18 45 0 5 23 M Left Cam 1 3 1 8 25 25 80 67 12 23 47 15 17 Arthroscopy 6 30 M Right Mixed 1 0 1 1 35 6 59 62 1 33 42 13 18 44 0 7 16 F Right Mixed 0 0 1 1 42 36 65 40 3 34 40 15 18 48 0 8 19 F Right Pincer 0 0 1 3 39 32 52 46 4 25 40 14 15 26 Arthroscopy, PAO 9 29 F Left Cam 0 0 2 5 29 20 61 50 7 28 50 14 15 29 0 10 35 F Right Cam 0 3 1 2 29 22 62 59 4 27 42 15 17 47 0 11 34 M Right Cam 1 3 4 2 27 30 63 55 2 26 46 16 18 47 0 12 26 M Right Mixed 1 3 1 3 36 14 106 56 1 28 50 15 17 46 0 13 36 F Left Cam 0 0 1 9 29 35 56 53 9 23 42 14 18 48 0 14 26 F Right Mixed 1 0 1 1 36 40 61 54 3 28 45 13 17 36 0 15 31 F Right Cam 0 0 1 0 33 5 55 51 2 27 44 15 17 34 0 16 31 M Left Cam 0 3 1 7 28 20 74 58 8 26 45 14 17 34 0 MRI, magnetic resonance imaging. OHS not acquired in one patient due to tumor-related neurologic problems newly developed during the follow up period. 52  J. Weidner et al. Fig. 6. Boxplot of the pre- and postoperative Merle d’Aubigne´ and Postel score. Fig. 7. Boxplot diagram comparing the pre- and postoperative MdA score for Group 1 (with previous surgery) and Group 2 (no previ- ous surgery). labrum is preserved and augmented by a graft. The rationale dislocating the hip again after performing the augmentation. of the technique is (i) to maintain the hoop stress capability A characteristic vacuum sound is heard if the seal is restored by preserving the intact tip of the labrum and (ii) to improve correctly. This gives additional confirmation of a technically the sealing effect of the labrum by adding volume to it. This good reconstruction. The open technique also allows to re- is achieved by placing a ligamentum teres graft between the adjust graft and suture placement in order to achieve a func- bony rim and the preserved part of the labrum. The ligamen- tional reconstruction. tum teres is an ideal graft for this as it can easily be harvested We observed inferior results regarding the clinical out- during surgical hip dislocation and has no additional morbid- comes in the patient group with previous hip surgery. In all ity. An alternative source for a graft that can be used in the patients who had hip arthroscopies with cam resection and same way is the fascia lata. With the open approach, the res- labral refixation before, we saw a variable degree of intraar- toration of the suction seal effect can be easily controlled by ticular adhesions. In two cases, the offset correction was Downloaded from https://academic.oup.com/jhps/article-abstract/5/1/47/4812017 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Labral augmentation with ligamentum capitis femoris  53 not carried out completely by the arthroscopic procedure. REFERENCES In one patient, the magnetic resonance imaging revealed 1. Bsat S, Frei H, Beaule´ PE. The acetabular labrum. Bone Joint J extensive intraarticular adhesions and a recurrence of the 2016; 98-B: 730–5. offset pathology as well as additional osteophytes at the 2. Miozzari HH, Celia M, Clark JM et al. No regeneration of the femoral head–neck junction 1 year after hip arthroscopy. human acetabular labrum after excision to bone. Clin Orthop Relat Res 2015; 473: 1349–57. In the same patient, the actabular labrum was clumsy with 3. Espinosa N, Beck M, Rothenfluh DA et al. Treatment of femoro- an insufficient suction seal. 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Investigation of the preser- vation of the fluid seal effect in the repaired, partially resected, persistence of FAI symptoms and progression of cartilage and reconstructed acetabular labrum in a cadaveric hip model. damage. 50% of patients in this group had OA Grade 1, Am J Sports Med 2012; 40: 2218. while only 42% had Grade 1 OA in the group with no pre- 6. Ferguson SJ, Bryant JT, Ganz R et al. An in vitro investigation of vious surgery. Obviously, the patients with previous sur- the acetabular labral seal in hip joint mechanics. J Biomech 2003; geries had a longer history of hip pain before the labral 36: 171–8. augmentation was performed. In this context, it can be dis- 7. Ferguson SJ, Bryant JT, Ganz R et al. The acetabular labrum seal: cussed if a certain degree of chronification of pain could a proroelastic finite element model. Clin Biomech 2000; 15: 463–8. add to the inferior results in this group. 8. Nepple JJ, Philippon MJ, Campbell KJ et al. The hip fluid seal - Part II: The effect of an acetabular labral tear, repair, resection, Our results regarding the clinical scores are comparable and reconstruction on hip stability to distraction. Knee Surg Sports to the clinical outcome reported in a previous study that Traumatol Arthrosc 2014; 22: 730–6. used the ligamentum capitis femoris for labral reconstruc- 9. Philippon MJ, Nepple JJ, Campbell KJ et al. The hip fluid seal - tion instead of labral augmentation [19]. Part I: The effect of an acetabular labral tear, repair, resection, Limitations of the study are due to its retrospective na- and reconstruction on hip fluid pressurization. Knee Surg Sports ture. The study group consists of a relatively small number Traumatol Arthrosc 2014; 22: 722–9. of patients and has a limited follow-up period. We did not in- 10. Philippon MJ, Briggs KK, Hay CJ et al. Arthroscopic labral recon- struction in the hip using iliotibial band autograft: technique and clude a control group. On one hand, it would be difficult to early outcomes. Arthroscopy 2010; 26: 750–6. compare the results of our study group to another patient 11. Ito K, Leunig M, Ganz R. Histopathologic features of the acetabu- group requiring surgical hip dislocation. Also, we did not aim lar labrum in femoroacetabular impingement. Clin Orthop Relat to compare our results to other techniques. The purpose of Res 2004; 429: 262–71. this study was to present the technique of labral augmenta- 12. Griffin DR, Dickenson EJ, O’Donnell J et al. The Warwick agree- tion using the ligamentum teres and to report on our initial ment on femoroacetabular impingement syndrome (FAI syn- results after 1 year. The results are based on the adequate drome): an international consensus statement. Br J Sports Med 2016; 50: 1169–76. restoration of the suction seal which is directly tested intrao- 13. Beck M, Kalhor M, Leunig M et al. Hip morphology influences peratively and on clinical results. However, there are no ob- the pattern of damage to the acetabular cartilage. J Bone Joint Surg jective tests to report on the effect of the labral Br 2005; 87: 1012–8. augmentation on the restoration of the suction seal. 14. Tannast M, Siebenrock KA, Anderson SE. Femoroacetabular im- The intraoperative findings after performing labral augmen- pingement: radiographic diagnosis - what the radiologist should tation with the technique described demonstrated an adequate know. AJR 2007; 188: 1540–52. restoration of the suction seal. The overall clinical results after 15. D’Aubigne´ RM, Postel M. Functional results of hip arthroplasty a 1 year follow-up were good. When compared with patients with acrylic prosthesis. J Bone Joint Surg Am 1954; 36:451–75. 16. Murray DW, Fitzpatrick R, Rogers K et al. The use of the Oxford without previous surgery, patients who had undergone failed hip and knee scores. J Bone Joint Surg Br 2007; 89: 1010–4. joint preserving hip surgery before had inferior results. 17. Ganz R, Gill TJ, Gautier E et al. Surgical dislocation of the adult hip. J Bone Joint Surg Br 2001; 83: 1119–24. 18. Beck M, Leunig M, Parvizi J et al. Anterior femoroacetabular im- ACKNOWLEDGEMENT pingement: mid- term results of surgical treatment. Clin Orthop We thank K. Oberli for creation of the line drawings. 2004; 418: 67–73. 19. Camenzind RS, Steurer-Dober I, Beck M. Clinical and radio- CONFLICT OF INTEREST STATEMENT graphical results of labral reconstruction. J Hip Preserv Surg; 2: None declared. 401–9. Downloaded from https://academic.oup.com/jhps/article-abstract/5/1/47/4812017 by Ed 'DeepDyve' Gillespie user on 16 March 2018

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Journal of Hip Preservation SurgeryOxford University Press

Published: Jan 1, 2018

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