month our esteemed panelists gave us a diverse yet balanced presentation
laying the foundation for this month’s Round Table discussion on
current and emerging surgical procedures for patients afflicted with
femoroacetabular impingement (FAI) and labral tears.
This Round Table began, quite honestly, as a
reaction to an arthroscopic labral reconstruction procedure (with gracilis
autograft) that was presented at this year’s Orthopedics
Today Hawaii conference. Some questions were related to technique; many
were justifiably related to rationale.
With the interest, research, and literature rapidly
expanding, my hope is to allow our expert panel to continue in stride as they
tackle the topic of what can be done and what should be done — which are
not necessarily the same — as all of us learn, often from each other,
about the rapidly evolving management of young adults with hip pain.
Dean K. Matsuda, MD
|Round Table Participants
Dean K. Matsuda, MD
Director of Hip
Co-Chair of Sports Medicine
Los Angeles, Calif.
Philip C. Noble, PhD
Department of Orthopedic Surgery
Baylor College of
Marc J. Philippon, MD
Steadman Hawkins Clinic
Thomas G. Sampson, MD
Total Joint Center
Saint Francis Memorial Hospital
Medical Director of
Post Street Surgery Center
San Francisco, Calif.
Robert T. Trousdale, MD
Mayo Clinic College of Medicine
Dean K. Matsuda, MD: What are your indications
for surgical intervention in cases of FAI?
Marc J. Philippon, MD: Patients usually present
for treatment of disabling hip pain. They have usually failed conservative
treatment and come to our facility for surgical intervention. Patients are
encouraged to seek early intervention. Time from onset to surgery does
correlate with outcomes following hip arthroscopy.
Our study showed that patients who waited more than 1
year and who had an alpha angle greater than 55· were 9.5 times more
likely to have grade III/IV chondral defects. This suggests that early
intervention may lead to improved patient outcomes in patients with
debilitating hip pain.
Other indications for surgery included physical exam and
radiographic diagnosis of FAI.
Thomas G. Sampson, MD: My indication for
arthroscopic hip surgery is anyone who has pain from the hip joint for more
than 6 months with or without a specific diagnosis and has failed any
conservative care. For FAI, there is no known conservative treatment unless it
is due to hyperlordosis of the lumbar spine, which can be treated by a physical
I reserve a steroid injection for those who are
extremely symptomatic and hesitant to have surgery or, for some reason, delay
it. The fact that symptoms may abate in FAI doesn’t mean the problem has
gone away. There is still an ongoing destructive process that may cause
symptoms to wax and wane.
Robert T. Trousdale, MD: Our general indications
for surgical intervention include pain bad enough to warrant surgery and
structural problems that one can improve upon in the presence of reasonable
articular cartilage. That includes an acetabular osteotomy if the dysplasia
problem is worse on the pelvic side, a femoral osteotomy if the deformity is
worse on the femoral side or, on occasion, a combination of both femoral and
If a young patient has structural problems of
impingement on the acetabular side or femoral side we try to solve all the
structural problems that are present. I think the patient who is middle-aged
— older than 40 or 50 years — we are less likely to do a major open
intervention in light of the fact that the secondary chondral problems are
often marked. The younger the patient, the more likely we are going to accept
more significant arthritic problems in the joint.
Matsuda: What procedures do you typically perform
in the management of hip labral pathology?
Philippon: To treat labral pathology, you must
treat all factors that may have caused the pathology and all concomitant
pathologies which may limit the patient’s full recovery.
The femoral head and neck are resected with a 5.5-mm
burr prior to labral repair in order to assess the repair during dynamic exam.
The decision to repair or debride the labral pathology is made
intraoperatively. Degenerative labral tears are debrided using thermal and/or
shaving techniques. Frayed, flap, and small labral tears with enough viable
healthy tissue remaining to provide anatomic function are also debrided.
All other labral pathologies are repaired using suture
anchors with either circumferential or mid-substance capture. In the cases of
pincer-type FAI, it was sometimes necessary to extend the labral tear using an
arthroscopic knife entered precisely at the chondro-labral junction. The labral
tear can then be carefully extended to allow adequate access for the 5.5-mm
motorized burr to decompress the underlying pincer lesion.
In most cases, the labrum can then be reattached and
repaired using suture anchors to restore an anatomic labral seal and
femoroacetabular labral articulation. If a short segment of the labrum is
involved with the pincer lesion, then the labrum can remain attached. However,
we have seen in revision cases that the segment was too long and the labrum
If the labrum is unstable on dynamic exam, then extend
the detachment and rim trimming. In order to prevent over trimming the rim and
the potential of dysplasia, we measure the depth of the lunate surface at the
12 o’clock position before and after rim trimming. This depth is related
to the change in the center-edge (CE) angle by the following formula: Change in
CE angle = 1.8 + (0.64 × rim reduction in millimeters). The formula is to
be applied only in instances in which a rim trimming is performed and at least
1 mm of rim is resected. A measurement of less than 1 mm lacks accuracy in
determining the relationship.
When a chondral defect is near the chondro-labral
junction, rim trimming can also be used to decrease the size of the chondral
We then use the microfracture technique to treat the
chondral defect. The chondral defect on the femoral head is also treated with
microfracture if the cartilage rim around the defect is of adequate depth to
hold the clot. Synovectomy and lysis of adhesions should also be addressed, as
they are possible pain generators following surgery. The capsule is sutured at
the site of the initial capsulotomy.
There are occasions, however, in which the labrum cannot
be repaired primarily. The labral tear pattern can be complex and completely
disrupt the longitudinal fibers, which leaves little functional material to
repair. In these cases, we use an autograft illiotibial band to reconstruct the
Sampson: The surgical treatment for non-FAI
labral pathology varies depending on the tear type, the association with
degenerative joint disease (DJD), and the age and activity level of the
In most of my cases, it simply requires partial
labrectomy. I think there are rare cases after trauma in a young patient where
a bucket handle usually associated with a posterior subluxation or dislocation
benefits from a repair, however most that I have seen were too frayed for
repair and were debrided. I have found it rare to perform a labral repair in my
patient population, which averages in the 30 to 40 year-old age range.
Trousdale: If the patient is younger and has
major structural problems, we will solve the structural problem about the hip
joint and deal with the labral pathology. In the vast majority of patients we
try to repair the labrum if it is a repairable lesion — a tear from the
osseous surface. If there is peripheral tearing, we will debride that tear.
In patients with dysplasia, we will solve the dysplastic
problem. In patients with a retroverted acetabulum in the face of poor
posterior wall coverage, we will do an anteversion periacetabular osteotomy. In
classic dysplasia we will do a classic periacetabular osteotomy. If there are
impingement problems we will try to solve the impingement situation.
In patients with pincer-type acetabular impingement, if
they have a deep socket (coxa profunda) or protrusio defect we will lessen the
depth of the socket. In patients with a retroverted socket, if they have
adequate posterior wall coverage, we will do a labral take-down and anterior
rim trimming. In patients who, as mentioned above, have a retroverted socket in
the face of poor posterior wall coverage, we will do a reverse (anteverting)
We have done, and recently published in Clinical
Orthopaedics and Related Research, our technique for labral
reconstruction. We have taken the round ligament and used that as a
reconstructive tissue for the labrum. That, I think, should be considered
experimental as there is really no long-term outcome.
Matsuda: Dr. Philippon, could you describe your
arthroscopic supine approach?
Philippon: The patient is placed in a modified
supine position with a combination of general anesthesia and a lumbar plexus
sciatic regional block with complete muscular paralysis. The perineum is
positioned against an extra-wide, padded bolster with care taken to protect the
genitalia. Both legs are positioned in 40· of adduction, 20· of
flexion, and neutral rotation.
Fluoroscopy is used to obtain an AP view of the
operative hip. Gentle traction is applied through the operative hip with
moderate counter-traction through the nonoperative hip until the development of
a “vacuum sign” in the joint space. Once this has been visualized,
the operative leg is adducted to neutral and the foot is maximally internally
rotated to bring the femoral neck parallel to the floor.
Joint distraction is assessed with fluoroscopy and
additional traction, usually 25 to 50 pounds total, is applied to achieve
approximately 10-mm total distraction. Once final traction is established, the
operative table is tilted 10· toward the nonoperative side.
All images are of supine patient viewed
from the anterolateral portal. Figure 'a' shows anterosuperior acetabular rim
after rim trimming and suture anchor drill hole (yellow arrowheads)
preparation. Figure 'b' shows the gracilis tendon autograft being attached via
the modified mid-anterior portal. Figure 'c' shows the labral reconstruction
prior to release of intermittent hip distraction.
Image: Matsuda DK
Matsuda: What is the future of hip preservation
Philip C. Noble, PhD: A disturbing number of
patients seek treatment when chondral damage has occurred and less successful
treatments, like microfracture, are all that can be offered. In some of these
cases, early detection of labral and chondral pathology may help preserve the
joint through guiding earlier intervention.
Clearly, we need to know more about the success of
osteochondroplasty and labral refixation in terms of long-term joint health and
not simply short-term symptomatic relief. Rigorous work-up of cases already
performed using newer imaging modalities can provide valuable insights into the
success of attempts to reattach the labrum and restore the chondral seal, and
the response of the articular surface to improved lubrication and a reduction
of chronic inflammation. Modalities including ultrasound imaging and functional
magnetic resonance imaging (FMRI) should be utilized to learn more about what
we have achieved to date as a springboard for the next advances.
Unfortunately, we have limited options for improving
labral fixation and chondral repair as most of the challenges are biological
and not mechanical. The greatest problem confronting us is the management of
chondral delamination, especially where lesions are present on both the femoral
head and the mating acetabulum.
It is also unclear whether labral reattachment will be
successful in the long-term when performed on a broader scale than at present
given the technical demands of the procedure. Solutions to tissue attachment
which look promising include:
- the use of tissue scaffolds for articular repair and attachment;
- the incorporation of angiogenic growth factors into the reattached
labrum and the chondro-labral junction to stimulate vascular ingrowth;
- the use of surgical adhesives, especially those based on
artificially engineered proteins, to restore the integrity of the
chondro-labral and cartilage-bone interfaces; and
- the development of an artificial labrum as an option to prolong the
natural joint before resorting to prosthetic replacement of the articulating
Sampson: To predict the future of hip
preservation, we need to understand how hips are destroyed. Let us use the
modal of osteoarthritis (OA). It has become more accepted that OA may be caused
by abnormal morphology of the hip joint such as FAI, developmental dysplasia
(DDH) or coxa magna from old Perthes disease. All of these conditions cause
mechanical destruction of the articular cartilage and labrum by a high
concentration of forces on mismatched articular surfaces. The reaction to the
generated particulate matter is a physiologic response with synovitis and the
secretion of digestive enzymes and scavenger cells which cause further
destruction of the joint.
The goals of joint preservation surgery are to correct
the abnormal morphology to create a concentric articulation, and reverse the
destructive biologic response to eliminate the synovitis.
I advocate performing a correction of cam bumps, rim
osteophytes and excess head mass — using arthroscopic means whenever
possible, especially in those who already have OA and are young with Harris Hip
scores greater than 60. We have found that good predictors of success are both
hip rotation and joint space greater than 50% of the unaffected hip. Poor
predictors include X-ray or MRI evidence of large acetabular cysts, complete
overgrowth of the notch by osteophyte, complete ossification of the transverse
ligament, and large inferior and posterior femoral head osteophytes. All of the
predictors indirectly reflect the nature or the remaining articular hyaline
cartilage cells and their matrix.
The challenges are to restore the morphology before the
mechanical forces have caused irreversible cartilage cell death and inability
for cartilage matrix regeneration.
For the future, we need a method to determine whether
the joint has crossed an irreversible threshold so we may determine which hips
will have predictably good outcomes with surgery.
With arthroscopic hip surgery, we have all of the tools
and abilities to examine the hip, biopsy pathologic and normal-appearing
tissues, and change the morphology using current techniques described in
treating FAI in an outpatient setting with minimal morbidity and an easier
rehabilitation than open techniques.
The addition of cartilage cellular analysis
preoperatively using noninvasive imaging, and intraoperatively with biopsy or
probes, would satisfy our abilities to predict and prognosticate outcomes from
hip preserving surgery in those who already have OA.
Chemical labeling PET scans and high resolution MRI is
still in its early stages of identifying cartilage integrity, however, it is
already useful, if available.
Trousdale: I think we have a reasonable handle on
the structural problems that lead to impingement and arthritis. What we
don’t know is the long-term outcome of various operations. We do not know
if the interventions that we do are going to change the natural history of the
The future involves cartilage restoration techniques.
Matsuda: I predict that we will trend towards
more minimally invasive options in the management of focal, eg, acetabular
retroversion, and even global, eg, coxa profunda or protrusio acetabulae, FAI.
Improved techniques and instruments are on the horizon. Labral reconstruction
in select patients will play a role in hip preservation.
We will better understand the biomechanical effects and
consequences of our acetabular procedures; this will enable us to determine who
should have a rim trimming procedure and who may fare better with a reverse
periacetabular osteotomy (PAO).
Moreover, I predict that endoscopic Bernese PAO will
become a possible —perhaps even preferred — management for select
patients with dysplasia and/or focal FAI.
Arthroscopic techniques will expand their utility in the
trauma setting. Treatment of displaced femoral head fractures and acetabular
rim stress fractures have recently been published. And although not necessarily
hip preservation our expertise will expand into the area of the central pelvis
as we learn more about the multitude of conditions that contribute to athletic
pubalgia, thus making us more complete surgeons.
For more information:
- Dean K. Matsuda, MD, can be reached at Southern California
Permanente Medical Group, Kaiser West Los Angeles Medical Center, 6041 Cadillac
Ave., Los Angeles, CA; 323-857-4477; e-mail:
He has intellectual property rights with ArthroCare.
- Philip C. Noble, PhD, can be reached at Institute of Orthopedic
Research & Education, 6550 Fannin-Smith Tower, Ste. 2512, Houston, Texas
77030; 713-441-3010; e-mail: firstname.lastname@example.org. He receives royalties from Smith &
Nephew, Stryker and Zimmer; is a paid consultant or employee of, and receives
research or institutional support from Smith & Nephew and Zimmer; and
receives miscellaneous non-income support from Biomet, Smith & Nephew and
- Marc J. Philippon, MD, can be reached at 181 W Meadow Drive, Ste.
400, Vail, CO 81657; 970-476-1100; e-mail:
email@example.com. He receives royalties from
Smith & Nephew and Bledsoe; is on the speaker’s bureau and is a paid
or unpaid consultant for and receives non-income support from Smith &
Nephew and receives institutional or research support from Smith & Nephew
- Thomas G. Sampson, MD, can be reached at Post Street Orthopaedics
and Sports Medicine, 2299 Post St., Suite 107, San Francisco, California
94115-3443; 415-345-9400; e-mail:
He receives royalties from Smith & Nephew.
- Robert T. Trousdale, MD, can be reached at Mayo Clinic, 200 First
St. SW E14B, Rochester, MN 55905; 507-284-3663; e-mail:
firstname.lastname@example.org. He receives research or
institutional support, miscellaneous funding and royalties from and is a
consultant to DePuy and he is a consultant to Wright Medical Technology.
- Sierra RJ, Trousdale RT. Labral reconstruction using the
ligamentum teres capitis: report of a new technique. Clin Orthop Relat