Arthroscopic Reconstruction of the Irreparable Acetabular Labrum: A Match-Controlled Study with Minimum Two-Year Follow-Up

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1 Arthroscopic Reconstruction of the Irreparable Acetabular Labrum: A Match-Controlled Study with Minimum Two-Year Follow-Up Siva Chandrasekaran, MBBS FRACS Nater Darwish, BS Brian H Mu, BS Dan Rybalko, MD Itay Perets, MD, Eddie O. Chaharbakshi, BS Carlos Suarez, MD, Benjamin G. Domb, MD

2 Disclosures American Orthopedic Foundation a, American Hip Foundation a, AANA Learning Center Committee a, Adventist Hinsdale Hospital c, Hinsdale Hospital Foundation a, Hinsdale Orthopedic Associates e, Hinsdale Orthopedic Imaging e, American Hip Institute e, Arthroscopy Journal a, SCD#3 e, North Shore Surgical Suites e, Munster Specialty Surgery Center e, Amplitude c, Arthrex b,c,d, DJO Global d, Medacta b,c, Orthomerica d, Stryker b,c a boardmember; b research support; c consulting; d royalty; e ownership interest

The technique of labral reconstruction has been developed to restore labral function in the setting of a young patient with minimal arthritis and

3 Background & Purpose When the labrum is deficient, o o o 43-60% less force is required to distract the femur cartilage degeneration occurs 40% faster 92% increase in femoroacetabular stresses from shifting the hip loadbearing surface. The technique of labral reconstruction has been developed to restore labral function in the setting of a young patient with minimal arthritis and an irreparable or deficient labrum. Purpose: To report clinical outcomes of arthroscopic labral reconstruction in the hip at minimum two-year follow-up in comparison to a pair-matched labral repair group.

4 Methods Patient Selection, Matching Selection and Outcomes 1 2A o Inclusion: underwent labral reconstruction during hip arthroscopy and had minimum two-year follow-up data from Sept 2010 to Nov o Exclusion: active workers compensation claims or previous ipsilateral hip surgery or conditions. Matching 2B o Reconstruction patients were matched 1:2 to patients that underwent arthroscopic labral repair but otherwise met all inclusion and exclusion criteria. o Matching criteria were age within five years, sex, body mass index (BMI) within five, same capsular treatment, and whether there was chondral damage of Outerbridge grade II or greater. Outcomes o Modified Harris Hip Score (mhhs), Non-arthritic Hip Score (NAHS), Hip Outcome Score Sports Subscale (HOS-SS), and pain rated on a 0-10 visual analog scale (VAS) were recorded preoperatively and at a minimum of two years postoperatively. o International Hip Outcome Tool (ihot-12) and patient satisfaction were also collected at latest follow-up.

Methods Surgical Technique The non-functional part of the

measuring probe Graft choices for reconstruction included the

5 Methods Surgical Technique The non-functional part of the diseased labrum was debrided with a 5 mm shaver until healthy edges were achieved. The size of the defect was measured by an arthroscopic measuring probe Graft choices for reconstruction included the ipsilateral gracilis tendon harvested from the knee or a semitendinosis allograft. The graft was then prepared in a doubled-over fashion with Krackow stitches to a length of approximately 2 mm longer than the measured defect length on each side.

The posterior end of the graft was anchored to the most lateral aspect of the labral defect.

6 Methods Surgical Technique The anterior end of the graft was anchored at the anterior edge of the site of segmental loss of the labrum using a 2.9-mm PushLock anchor (Arthrex, Inc.; Naples, FL). The posterior end of the graft was anchored to the most lateral aspect of the labral defect. The middle portion of the reconstructed labrum was then anchored to the rest of the predrilled holes on the acetabular rim using a simple loop technique.

7 Results - Demographics Reconstruction Repair p-value Patients Age (years) 37.3 ± 12.2 ( ) 38.4 ± 12.3 ( ) Sex > Female 16 (47.1%) 32 (47.1%) Male 18 (52.9%) 36 (52.9%) BMI 26.9 ± 4.7 ( ) 26.9 ± 4.2 ( ) Follow-up time 36.8 ± 13.8 ( ) 42.8 ± 21.0 ( ) (months) Secondary arthroscopy 4 (11.8%) 8 (11.8%) > Time (months) 17.5 ± 14.2 ( ) 21.3 ± 16.9 ( ) Conversion to THA 4 (11.8%) 6 (8.8%) Time (months) 18.1 ± 7.4 ( ) 21.7 ± 16.7 ( ) Complications 4 (11.8%) 8 (11.8%) > 0.999

8 Results Intra-operative findings and Procedures Reconstruction Repair p-value Labral tear Seldes I 5 (14.7%) 33 (48.5%) Seldes II 11 (32.4%) 16 (23.5%) Seldes I & II 18 (52.9%) 19 (27.9%) Labral tear size 3.8 ± ± (hours) Posterior end 11.1 ± ± 1.1 < Anterior end 14.9 ± ± ALAD (5.9%) 1 (1.5%) 1 4 (11.8%) 11 (16.2%) 2 7 (20.6%) 27 (39.7%) 3 20 (58.8%) 25 (36.8%) 4 1 (2.9%) 4 (5.9%) Acetabular Outerbridge 0 2 (5.9%) 1 (1.5%) I 4 (11.8%) 11 (16.2%) II 9 (26.5%) 26 (38.2%) III 13 (38.2%) 23 (33.8%) IV 6 (17.6%) 7 (10.3%) Femoral head Outerbridge 0 30 (88.2%) 55 (80.9%) I 0 (0%) 1 (1.5%) II 3 (8.8%) 3 (4.4%) III 0 (0%) 7 (10.3%) IV 1 (2.9%) 2 (2.9%) Ligamentum teres tear (50.0%) 32 (47.1%) Partial 15 (44.1%) 30 (44.1%) Complete 2 (5.9%) 2 (2.9%) Reconstruction Repair p-value Labral treatment < Reconstruction 34 (100%) 0 (0%) Repair 0 (0%) 68 (100%) Capsular treatment > Release 20 (58.8%) 40 (58.8%) Repair/Plication 14 (41.2%) 28 (41.2%) Acetabular rim trimming Femoral neck osteoplasty Acetabular microfracture Femoral head microfracture Iliopsoas fractional lengthening Trochanteric bursectomy Gluteus medius repair 34 (100%) 55 (80.9%) (91.2%) 61 (89.7%) > (5.9%) 7 (10.3%) (0%) 1 (1.5%) > (47.1%) 29 (42.6%) (20.6%) 8 (11.7%) (2.9%) 2 (2.9%) > 0.999

9 Results - Outcomes Both the reconstruction and repair groups saw statistically significant increases in all PRO measures and decreased VAS at minimum two-year follow-up.

Limitations This study involved minimum two-year follow up and it is unknown whether the improvement demonstrated will persist over time or whether there will be a recurrence of pain.

10 Limitations This study involved minimum two-year follow up and it is unknown whether the improvement demonstrated will persist over time or whether there will be a recurrence of pain. The possible confounding effects of hamstring allograft or autograft on treatment outcomes. However, A recent review by Ayeni et al. found that graft type did not influence outcome. Both arthroscopic techniques have different indications. Labral reconstruction is indicated for the young patient with minimal arthritis and an irreparable labral. The rationale for comparing the techniques is that both attempt to restore the labral seal. Both techniques have varied rehabilitation protocols, which are unlikely to be significant at two-year follow up.

11 Conclusions Arthroscopic labral reconstruction is a safe and effective procedure for the treatment of irreparable segmental deficiencies of the labrum. It is associated with significant improvement in PROs and a low incidence of secondary surgery within twoyear follow-up. Improvements in PROs, VAS, patient satisfaction, and incidence of secondary procedures were comparable to a match control treated with labral repair. However, longer-term follow-up is needed to determine if these results persist.

12 Siva Chandrasekaran, MBBS FRACS, Nader Darwish, BS, Brian H Mu, BS, Dan Rybalko, MD, Itay Perets, MD, Eddie O. Chaharbakshi, BS, Carlos Suarez, MD,, Benjamin G. Domb, MD

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Results of Arthroscopic Labral Reconstruction of the Hip in Elite Athletes

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