ARTHROSCOPIC FASCIA LATA ALLOGRAFT RECONSTRUCTION ...€¦ · 10/10/2015  · Hospital for Special Surgery. 2012;8: 225-229. 9. Espinosa N, Rothenfluh DA, Beck M, Ganz R, Leunig M.

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D O M I N I C S . C A R R E I R A M . D .

A S S I S T E D B Y RYA N E N D E R S F O R T L A U D E R D A L E , F L

ARTHROSCOPIC FASCIA LATA ALLOGRAFT RECONSTRUCTION:

TECHNIQUE AND EARLY RESULTS

DISCLOSURE

•  Consultant for Biomet including education and product development

INTRODUCTION

Femoroacetabular Impingement(FAI) is abnormal contact between the proximal femur and rim of the acetabulum. There are

3 types of FAI: CAM, Pincer, or Mixed; each may lead labral damage causing pain in affected patients.

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DAMAGE TO THE ACETABULAR LABRUM

REPAIR VS. RECONSTRUCTION

1) What constitutes “irreparable”? 2) Debridement associated with less than optimal outcomes 3) Should Tx options be dictated by degree of labral injury?

•  Debridement à Repair à Reconstruction

RELATIVE INDICATIONS FOR RECONSTRUCTION

•  Labral Deficiency (after debridement or hypoplastic)

•  Complex Labral Tearing •  Extensive Labral Bruising •  Absent Longitudinal Tissue •  Advanced Degeneration

•  Including Calcification

•  Iatrogenic (bailout if primary repair fails) •  Os Acetabuli

Combination of these factors!

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DEFINE LABRAL INJURY

Hypoplastic, Complex tearing, Extensive bruising

COMPLEX LABRAL TEARING

DEGENERATED AND CALCIFIED LABRUM

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MORE AGGRESSIVE RIM TRIMMING

• Can remove a significant amount of arthritis

•  Majority of Impingement cartilage wear is frequently located on redundant part of the cup

• Can make a labrum that fits your new cup

KNEE MENISCUS ALLOGRAFT AS A MODEL

•  Several studies have consistently demonstrated patient satisfaction rates ranging from 70 to 90% > 2 years after surgery1, 2, 6.

CARREIRA RESULTS

•  54 hips •  Minimum follow up was 12 months (mean of 20 months) •  Allograft versus control group

•  Age 45 vs 39 •  Microfracture %: 43 versus 21 •  Acetabular chondroplasty %: 63 vs 37

•  Complications: •  Temporary neuropraxias were noted in 4% of patients.

•  One patient had a superficial portal infection which resolved with oral antibiotics.

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Based on the mHSS, the overall failure rate was 11%.

EARLY OUTCOMES

0

10

20

30

40

50

60

70

80

90

HHS ADL HHS Gait HHS Pain HHS Total

Tegner SF-12 Mental

SF-12 Physical

HOS ADL iHOT-12

PreOp PostOp 1 Yr PostOp 2 Yr

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POINTS OF COMPARISON

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ALLOGRAFT ITB RECONSTRUCTION

142 patients (152 hips) 86% had complete follow-up at minimum of 2 years 18 hips (13.7%) required revision procedures at a mean of 17 months Of the remaining patients: mean MHHS improved by 34 points mean VAS pain score improved by

3 points at rest 4 points with ADLs 5 points with sport

overall satisfaction of 9 (range: 1-10)

White, accepted for publication, J Arthroscopy

WHY NOT JUST RESECT?

•  Although long term (>10yr follow-up) studies are yet to be published:

Debridement group associated with good to excellent outcomes in 55-70% 8,9,10,11,12

•  Much of this data was collected after only two years postop •  Extrapolate beyond?

PREPARING THE ACETABULUM

Marking depth of resection à eg, 5mm at apex

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ALLOGRAFT PREPARATION

University of Miami Tissue Bank provides the Fascia Lata allograft, which is tubularized on a back table

using a baseball stitch with 2-0 Vicryl. Avoid additional incision for harvest and potential

morbidity. Save surgical time

MAP

ADP

ALP

Right Hip Portal Placement

Isosceles Triangle

30º

ACCESSORY DISTAL PORTAL

Direct needle localization Through capsulotomy

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PERCUTANEOUS INSERTION OF ANCHOR AT ANTEROMEDIAL EXTENT OF DEFECT

THROUGH THE ACCESSORY DISTAL PORTAL (ADP) WITH A BLACK STRIPED SUTURE

INSERTION OF 2ND ANCHOR (BLUE) AT POSTEROLATERAL EXTENT OF DEFECT

• Measure chord length of excised area (c)

Based on these calculations, the arc length is 1.3x chord length

ALLOGRAFT SIZING

⎟⎠

⎞⎜⎝

⎛=rcrs2

arcsin*2

r c

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ALLOGRAFT SIZING

Distance between blue lines = 3 mm

Length allograft

(mm) = # of stripes in suture material x 3mm x 1.3

SHUTTLE SETUP Pull into Joint

ADD VIDEO OF SHUTTLE

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GRAFT INSERTED HALFWAY INTO JOINT AND SUTURE CROSSAGE ASSESSED

Black striped suture retrieved through modified MA portal

ANTEROMEDIAL END TIED FIRST, FOLLOWED BY POSTEROLATERAL END

BOTH ENDS OF LABRUM FIXATED

Remaining suture anchors placed in standard labral repair fashion

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ANTEROMEDIAL ANCHOR (RIGHT HIP EXAMPLE)

Standard 2.3mm anchor

BLACK striped sutures thru ADP

(blue 5.5mm cannula)

MAP

AL Viewing Portal

POSTEROLATERAL ANCHOR (RIGHT HIP EXAMPLE)

All suture BLUE striped anchor placed

through ALP (8.5mm cannula)

Hemostat together 2 suture limbs

ADP

MA viewing portal

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CARREIRA SHUTTLE TECHNIQUE (CONT.)

•  3) The camera is then placed in the ADP portal and a second labral repair cannula is placed at the MAP. One of the suture limbs from the anteromedial anchor (BLACK striped) is passed through the MAP and one limb is passed through the ALP.

•  4) Using a knot pusher, the limb from the anteromedial anchor located in the ALP is used to measure the number of crossing lines between the two anchors. The overall length can then be calculated.

CARREIRA SHUTTLE TECHNIQUE (CONT.)

•  5) A free needle is used to pass the suture material through the graft outside of the joint. One limb from each suture anchor passing through the ALP is tied securely to the graft, allowing enough space once passed for suture tying.

•  6) The limb from the MA portal is pulled and fully seated into the anteromedial anchor first, followed by the limb exiting the ALP. The limb connected to the anteromedial anchor is not fully seated until suture crossing has been checked and corrected if needed.

•  7) The ends of the labrum reconstruction are tied using a standard knot-tying technique.

•  8) Similar to a standard labral repair, the segment in between is tied with suture anchors.

SHUTTLE ALLOGRAFT & SECURE ENDS

1. Pass anchor suture thru each end of graft

using free needle

2. Deliver anterior end (BLACK striped) into joint and secure at

anchor

3. Pull BLUE striped suture to (shuttle) posterior end and anchor into place

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PLACE INTERVAL ANCHORS

PITFALL Make sure sutures are

not crossed prior to seating down fully

Once posterior and anterior graft are

anchored, intervening fixation similar to

standard labral repair

CONCLUSION

•  Patients demonstrate significant improvement with allograft labrum reconstruction.

•  The shuttle technique is safe, effective and avoids the need to fixate the free end of the graft from inside the joint.

•  Compared to historical controls of hip arthroscopy, this patient population may be:

•  Older •  Higher rate of chondroplasty and microfracture

FINAL THOUGHTS

•  Determination of reparable v irreparable

•  Ideal graft material •  Allograft v autograft? •  Fascia lata v tendons (hamstring)?

•  Define injuries and their outcomes across treatment techniques

Multicenter Arthroscopy Study Hip

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REFERENCES

1.  Cook, JL. The Current Status of Treatment for Large Meniscal Defects. Clinical Ortho. 2005;435:88-95.

2.  Lee, Sung Rak. Kim, Jin Goo. Nam, Sang Wook. The Tips and Pitfalls of Meniscus Allograft Transplantation. Knee Surg. And Relat. Research 2012;24(3): 137-145.

3.  Kim, CW. Kim, JM. Lee, SH. Kim, JH. Huang, J. Kim, KA. Bin, Si. Results of Isolated Lateral Meniscus Allograft Transplantation: focus on objective evaluations using MRI. Am. J. Sports Med. 2011;39: 1960-7.

4.  Philippon, Marc J. et al. Arthroscopic Labral Reconstruction in the Hip Using Iliotibial Band Autograft: Technique and Early Outcomes. Arthroscopy , Volume 26 , Issue 6 , 750–756.

5.  Ayeni OR, Alradwan H, de Sa D, Philippon MJ. The hip labrum reconstruction: indications and outcomes--a systematic review. Knee Surg Sports Traumatol Arthrosc. 2014 Apr; 22(4): 737–43.

6.  Verdonk PC, Demurie A, Almqvist KF, Veys EM, Verbruggen G, Verdonk R. Transplantation of viable meniscal allograft: Survivorship analysis and clinical outcome of one hundred cases. J Bone Joint Surg Am. 2005 Apr;87(4):715-24.

7.  Saltzman BM, et al. Prospective Long-Term Evaluation of Meniscal Allograft Transplantation Procedure: A minimum of 7-Year Follow-Up. J Knee Surg, 2012;25:165-176.

8.  Tibor, Lisa. Leunig, Michael. Labral Resection or Preservation During FAI Treatment? A Systemic Review. Hospital for Special Surgery. 2012;8: 225-229.

9.  Espinosa N, Rothenfluh DA, Beck M, Ganz R, Leunig M. Treatment of femoro-acetabular impingement: Preliminary results of labral refixation. J Bone Joint Surg Am. 2006;88:925–935.

10. Larson CM, Giveans MR. Arthroscopic debridement versus refixation of the acetabular labrum associated with femoroacetabular impingement. Arthroscopy. 2009;25:369–376.

11. Laude F, Sariali E, Nogier A. Femoroacetabular impingement treatment using arthroscopy and anterior approach. Clin Orthop Rel Res. 2009;467:747–752.

12. Philippon MJ, Briggs KK, Yen YM, Kuppersmith DA. Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction. Minimum two-year follow-up. J Bone Joint Surg Br. 2009;91:16–23.