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Management of a Large Acetabular Chondrolabral Injury in a Young Patient With Femoroacetabular Impingement

Open AccessPublished:December 08, 2014DOI:https://doi.org/10.1016/j.eats.2014.09.008

      Abstract

      Patients with mixed-type femoroacetabular impingement syndrome often have concomitant chondrolabral pathology in addition to the characteristic cam and pincer lesions. Unfortunately, these patients are typically young, and the pathology is localized to the weight-bearing dome of the acetabulum. Complete preoperative characterization of labral and cartilage lesions is often not possible even with advanced imaging techniques, and the full extent of the injury may not be appreciated without direct arthroscopic visualization. Thus management decisions regarding intra-articular pathology may not be possible until the time of surgery. Often, the cartilage and labral pathology in these young patients is part of a contiguous complex of tissue that separates from the underlying subchondral bone. We present an arthroscopic management technique for young patients with this pattern of injury. This includes limited debridement of loose labral and chondral tissue, labral repair to restore the suction-seal effect, microfracture to promote reparative tissue formation, and takedown of the underlying pathoanatomic cam and pincer lesions.

      Technique Video

      See video under supplementary data.

      Chondral injuries of the hip in the setting of femoroacetabular impingement are typically associated with labral tears.
      • McDonald J.E.
      • Herzog M.M.
      • Philippon M.J.
      Return to play after hip arthroscopy with microfracture in elite athletes.
      These lesions are often present in the anterosuperior aspect of the acetabulum as a result of repetitive abnormal contact with a pathoanatomic femoral cam lesion. In a normal hip, there is a contiguous transition from articular cartilage to labrum without gapping; however, in patients with femoroacetabular impingement–associated labral tears, the labrum most often remains partially attached to the acetabular rim, whereas the articular cartilage separates from the labrum and potentially delaminates from the subchondral bone, constituting a Seldes type I lesion.
      • Seldes R.M.
      • Tan V.
      • Hunt J.
      • Katz M.
      • Winiarsky R.
      • Fitzgerald R.H.
      Anatomy, histologic features, and vascularity of the adult acetabular labrum.
      These injuries are commonly seen in highly active, younger individuals at the weight-bearing acetabular surface.
      • Philippon M.J.
      • Weiss D.R.
      • Kuppersmith D.A.
      • Briggs K.K.
      • Hay C.J.
      Arthroscopic labral repair and treatment of femoroacetabular impingement in professional hockey players.
      They are often discovered to be high-grade Outerbridge chondral lesions at the time of arthroscopy
      • McDonald J.E.
      • Herzog M.M.
      • Philippon M.J.
      Return to play after hip arthroscopy with microfracture in elite athletes.
      and are frequently undetected on preoperative magnetic resonance imaging. Thus they represent a challenging surgical problem when encountered, and intervention may be determined based on intraoperative assessment alone (Fig 1).
      Fig 1
      Fig 1Preoperative axial T1 magnetic resonance arthrogram using a 1.5-T magnet showing a possible small labral tear at the superomedial aspect (arrow). No chondral pathology is identified. Underestimation of the extensive pathology visualized arthroscopically is not atypical in our experience using preoperative imaging.
      We report the technique of limited chondral debridement with labral repair and microfracture through the delaminated but attached cartilage (Table 1, Table 2). Although this technique is not without potential limitations, it allows for greater cartilage preservation without precluding future intervention should it be required in these young individuals.
      Table 1Intraoperative Pearls for Management of Large Seldes Type I Lesions in Young Patients
      Repair labral pathology with intact chondral transitional zones before addressing torn areas.
      Use a small-diameter suture passer to minimize the size of iatrogenic labral holes.
      Assess the acetabular cartilage while drilling for anchors to ensure that there is no joint penetration.
      Place anchors close to the subchondral bone to prevent lifting off of the labrum.
      Reassess the areas of chondral delamination after labral fixation because some areas may have been indirectly stabilized.
      Debride full-thickness unstable cartilage to a stable perpendicular rim.
      Consider limited chondral debridement of large flaps at the weight-bearing dome.
      Use a flexible drill to a depth of at least 6 mm for bone marrow stimulation.
      Space microfracture holes approximately 3 mm apart.
      Ensure adequate resection of pathoanatomic bony lesions.
      Assess the labral suction-seal effect with the leg removed from traction.
      Table 2Key Points
      Areas of cartilage destabilization are often part of a delaminated chondrolabral complex.
      The full extent of chondrolabral injuries is often not detected on preoperative MRI, and management decisions may be required based on intraoperative assessment.
      Labral repair is necessary to restore the suction-seal effect and frequently stabilizes adjacent chondral delamination.
      Limited debridement and microfracture through a large cartilage flap in a young, active patient with a large defect on the weight-bearing dome comprise a conservative initial option that does not preclude potential future management techniques, such as fibrin glue fixation or ACI.
      ACI, autologous chondrocyte implantation; MRI, magnetic resonance imaging.

      Surgical Technique

      Hip arthroscopy is performed in the typical supine position with the assistance of a Hip Distraction System (Arthrex, Naples, FL). The patient is positioned with neutral hip extension and slight adduction. Portals are established using fluoroscopic guidance and a set of tissue-compliant polymer cannulae in the form of the TransPort Hip Access System (Pivot Medical, Sunnyvale, CA) to facilitate intra-articular access. An anterolateral portal established under fluoroscopic guidance is primarily used for viewing with a 4.5-mm 70° arthroscope, and a midanterior portal is used for performing central-compartment work, particularly labral repair. A diagnostic arthroscopy of the central compartment is initially performed, and a capsulotomy connecting the midanterior to the anterolateral portal is made using a Samurai blade (Pivot Medical). Labral pathology is described in reference to a clock face, with the superior dome corresponding to the 12-o’clock position. In Video 1 the labral pathology extended from the 10- to 2-o’clock position with an associated chondral defect. Tearing is most often visualized at the chondrolabral transitional zone, and bubbling of the adjacent cartilage represents delamination (Fig 2).
      Fig 2
      Fig 2Arthroscopic assessment of a Seldes type I lesion (arrow) of the acetabular chondrolabral junction with separation of a large chondral flap from the labrum (asterisk) as viewed from the anterolateral portal with a 70° arthroscope. This lesion is found at the 1-o’clock position and corresponds to the weight-bearing dome.
      The labrum is first addressed, and the interval between the labrum and capsule is developed. Here, a large osseous bump consistent with a pincer lesion is often found and may potentially prevent successful reparative anchoring of the labrum. In this case 3 to 4 mm of bone was resected with a high-speed 4.5-mm round burr (Arthrex) to prevent further impingement and prepare a bony bed for labral repair. Care is taken during this step to avoid further destabilization of the labrum (Video 1). Intraoperative fluoroscopy is used to confirm placement of the burr and assess the extent of our resection (Fig 3).
      Fig 3
      Fig 3Intraoperative fluoroscopic assessment of the pincer lesion (A) before and (B) after resection. This technique allows for confirmation of the resection location with concurrent arthroscopic visualization.
      Labral fixation with suture anchors proceeds in a circumferential fashion, with a total of 4 required in our example (Video 1). A vertical mattress suturing technique of the labrum is performed with No. 2 FiberWire suture (Arthrex) that is passed with a curved NanoPass Suture Manager, Reach Crescent suture passer (Pivot Medical). Care is taken to ensure that the first pass is made at the labral base adjacent to its bony attachment and at the chondrolabral junction (Fig 4A). The second pass is made at the peripheral aspect of the labrum (Fig 4B). The suture is secured to the prepared bony bed with a PEEK (polyether ether ketone) PushLock 2.9-mm × 15.5-mm knotless suture anchor (Arthrex). While drilling for the anchor is performed, the joint should be visualized to ensure that there is no violation of the subchondral bone. Fixation of the labrum overlying a stable transitional zone should be performed before the area with the unstable flap is addressed. This allows for more accurate assessment of the amount of unstable cartilage that requires debridement because some of the chondral bubble may pull back and become stabilized indirectly with labral fixation alone. This allows for retention of as much native cartilage as possible in these young individuals. A microfracture technique is used to promote formation of fibrocartilage reparative tissue using a Phoenix Healing Response System Microfracture 0.9-mm 60° flexible curved drill (Pivot Medical) to a depth of 7 mm. With this method, holes are spaced approximately 3 mm apart. In this case we also performed limited microfracture through the adjacent cartilage that was not grossly unstable but was part of the adjacent bubble. The cartilage and labrum are then reassessed for stability, and restoration of the suction-seal affect is confirmed with the leg removed from traction. This is visualized in Video 1 while performing the cam femoroplasty.
      Fig 4
      Fig 4Arthroscopic technique for labral fixation using a vertical mattress stitch as viewed from the anterolateral portal with a 70° arthroscope. (A) The suture is initially passed at the base of the labrum (asterisks) adjacent to its bony attachment (arrow). (B) The suture is then retrieved through a second pass at the periphery of the labrum (arrow) to mitigate interposition of suture with the femoral head when traction is released.

      Discussion

      Several arthroscopic techniques have been described for management of both chondral and labral lesions. Options for management of labral injuries include selective, partial debridement
      • Kamath A.F.
      • Componovo R.
      • Baldwin K.
      • Israelite C.L.
      • Nelson C.L.
      Hip arthroscopy for labral tears: Review of clinical outcomes with 4.8-year mean follow-up.
      ; reconstruction
      • Karthikeyan S.
      • Roberts S.
      • Griffin D.
      Microfracture for acetabular chondral defects in patients with femoroacetabular impingement: Results at second-look arthroscopic surgery.
      ; and repair.
      • Philippon M.J.
      • Weiss D.R.
      • Kuppersmith D.A.
      • Briggs K.K.
      • Hay C.J.
      Arthroscopic labral repair and treatment of femoroacetabular impingement in professional hockey players.
      • Kamath A.F.
      • Componovo R.
      • Baldwin K.
      • Israelite C.L.
      • Nelson C.L.
      Hip arthroscopy for labral tears: Review of clinical outcomes with 4.8-year mean follow-up.
      • Philippon M.J.
      • Schenker M.L.
      • Briggs K.K.
      • Maxwell R.B.
      Can microfracture produce repair tissue in acetabular chondral defects?.
      • Byrd J.W.
      • Jones K.S.
      Primary repair of the acetabular labrum: Outcomes with 2 years' follow-up.
      • Jackson T.J.
      • Hanypsiak B.
      • Stake C.E.
      • Lindner D.
      • El Bitar Y.F.
      • Domb B.G.
      Arthroscopic labral base repair in the hip: Clinical results of a described technique.
      The goal of labral repair is to restore the suction-seal effect with the femoral head and stabilize any associated chondral delamination. The results of primary repair of the labrum have been largely successful, with high rates of arthroscopic second-look healing.
      • Byrd J.W.
      • Jones K.S.
      Primary repair of the acetabular labrum: Outcomes with 2 years' follow-up.
      • Jackson T.J.
      • Hanypsiak B.
      • Stake C.E.
      • Lindner D.
      • El Bitar Y.F.
      • Domb B.G.
      Arthroscopic labral base repair in the hip: Clinical results of a described technique.
      There are multiple options for fixation of the labrum to the acetabulum, most of which involve a circumferential, vertical suturing technique (Fig 5). Some surgeons advocate for a loop stitch passed circumferentially around the labrum, citing strong fixation.
      • Philippon M.J.
      • Schenker M.L.
      • Briggs K.K.
      • Maxwell R.B.
      Can microfracture produce repair tissue in acetabular chondral defects?.
      However, the labrum is compressed where the suture is passed using this technique, which may result in loss of the labral triangular cross-sectional configuration and compromise the suction-seal effect.
      • Jackson T.J.
      • Hanypsiak B.
      • Stake C.E.
      • Lindner D.
      • El Bitar Y.F.
      • Domb B.G.
      Arthroscopic labral base repair in the hip: Clinical results of a described technique.
      If the labrum is large enough to accommodate 2 suture passes (typically >5 mm), then fixation may be performed in a vertical mattress fashion.
      • Jackson T.J.
      • Hanypsiak B.
      • Stake C.E.
      • Lindner D.
      • El Bitar Y.F.
      • Domb B.G.
      Arthroscopic labral base repair in the hip: Clinical results of a described technique.
      This is our preferred technique when feasible.
      Fig 5
      Fig 5Previously described techniques. (A) Labral repair with a simple looped stitch passed circumferentially around the labrum, with the potential to cause bunching of the labrum and disruption of the contact seal. (B) The labral base stitch involves a single passage of suture through the base of the labrum, providing secure fixation of the labral base while preserving the free edge for contact with the femoral head, allowing the labrum to serve its function as a suction seal. (C) The labral base stitch with a vertical mattress technique involves 2 passes of the suture through the base of the labrum. This technique is recommended when the width of the labrum is at least 5 mm. (A, acetabulum; FH, femoral head; L, labrum.)
      Reprinted with permission from the Arthroscopy Association of North America.
      • Jackson T.J.
      • Hanypsiak B.
      • Stake C.E.
      • Lindner D.
      • El Bitar Y.F.
      • Domb B.G.
      Arthroscopic labral base repair in the hip: Clinical results of a described technique.
      In the Seldes type I lesion, the cartilage pulls away from the labrum and potentially delaminates from the subchondral bone, which may tear and become a painful, loose body. Thus, chondral intervention should also be performed concurrently with labral pathology treatment. Arthroscopic aggressive debridement of the chondral flap with microfracture for bone marrow stimulation and formation of a fibrocartilage plug in the setting of acetabular lesions has shown good healing potential.
      • Karthikeyan S.
      • Roberts S.
      • Griffin D.
      Microfracture for acetabular chondral defects in patients with femoroacetabular impingement: Results at second-look arthroscopic surgery.
      • Philippon M.J.
      • Schenker M.L.
      • Briggs K.K.
      • Maxwell R.B.
      Can microfracture produce repair tissue in acetabular chondral defects?.
      It is most often advisable to debride the chondral flaps to perpendicular edges to entrap the resulting clot and promote reparative fibrocartilage formation.
      • Philippon M.J.
      • Schenker M.L.
      • Briggs K.K.
      • Maxwell R.B.
      Can microfracture produce repair tissue in acetabular chondral defects?.
      However, the young individual with a large area of delaminated cartilage, particularly at the weight-bearing surface, represents a challenging problem because debridement of the loose cartilage would result in a large defect on the weight-bearing surface. Even as fibrocartilage is expected to fill in such defects, its biomechanical properties are inferior to those of native, hyaline cartilage.
      • Xing L.
      • Jiang Y.
      • Gui J.
      • Lu Y.
      • Gao F.
      • Xu Y.
      Microfracture combined with osteochondral paste implantation was more effective than microfracture alone for full-thickness cartilage repair.
      It is our experience that labral repair often indirectly stabilizes loose flaps of adjacent cartilage. Thus more native cartilage may be preserved by initially securing the labrum as opposed to first debriding loose, delaminated chondral flaps.
      Debridement of the loosest portions with microfracture through partially delaminated cartilage may be a preferable option to maintain the chondral surface, although some surgeons have noted inferior healing with this intervention in large defects.
      • Karthikeyan S.
      • Roberts S.
      • Griffin D.
      Microfracture for acetabular chondral defects in patients with femoroacetabular impingement: Results at second-look arthroscopic surgery.
      In these instances, other options would include more aggressive loose cartilage debridement, fibrin glue chondral fixation, and autologous chondrocyte implantation. The decision to perform limited chondral debridement and microfracture is often our preference in the young patient with large lesions on the weight-bearing surface. This technique provides a conservative initial surgical approach with a proven and effective basis in the form of microfracture for full-thickness chondral lesions and repair of a torn labrum. It also does not preclude use of other interventions in the future should the patient require additional surgery. On the basis of experience in the knee, potential limitations of this procedure include decreased effectiveness of microfracture in larger lesions, and microfracture through cartilage is theorized by some surgeons to potentially prevent stabilization of the resulting fibrin clot. Furthermore, we prefer use of a flexible drill to perform microfracture as opposed to an awl because the latter has been suggested to impact bone that prevents extravasation of fibrocartilage-promoting elements. We also drill to a depth of 7 mm to maximize involvement of remodeling subchondral bone, which may be important in inducing cartilage repair.
      • Chen H.
      • Chevrier A.
      • Hoemann C.D.
      • Sun J.
      • Ouyang W.
      • Buschmann M.D.
      Characterization of subchondral bone repair for marrow-stimulated chondral defects and its relationship to articular cartilage resurfacing.
      The long-term results of this technique used in the hip are lacking, and future studies are required in this regard.

      Supplementary Data

      References

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