This document discusses femoro-acetabular impingement (FAI), specifically examining the role of labrectomy (labrum removal) in treatment. It presents the case that repairing a damaged labrum may not restore normal hip biomechanics, while labrectomy removes a source of pain and impingement. The author conducted a study of 10 hips that underwent arthroscopic labrectomy for pincer or mixed FAI. Post-operatively, patients showed improved clinical scores up to 2 years follow-up, indicating labrectomy provides short-term pain relief in these cases. However, the study had limitations including a lack of long-term data or comparison to labral repair techniques.

1. Femoro-Acetabular impingement
DR M.N.BASU MALLICK
ARTHROSCOPY AND SPORTS SURGERY
APOLLO GLENEAGLES HOSPITAL,
KOLKATA
Does Labrectomy have a role?

2. Femoro acetabular impingement
 Abutment of the femoral head neck junction to the acetabular margin
 Causes intermittent pain initially, and continuous pain later. Clicking, locking
 Progresses to permanent damage to the labrum and cartilage, ending in OA hip
Diagnoses by Impingement tests
Xray –
 Abnormal head neck morphology (alfa angle)
 Acetabular retroversion (crossover sign)
 Coxa profunda (medialised teardrop)
Confirmation by MRI
Kassarjian triad of MR findings
 Abnormal head and neck morphology
 Anterosuperior cartilage abnormalities
 Anterosuperior labral abnormalities.

3. Patterns
CAM-
 Abnormal morphology of femoral head-neck jn - anterior aspect
 Young athletic males
 Shear injury - cartilage damage > labral damage
PINCER
 Acetabular margin projection
 Middle aged athletic females
 Osteophytes, coxa profunda, retroverted acetabulum
 Impaction injury – labral damage prominent
MIXED
 Commonest type
 SCFE
 Neck femur fractures
 Perthes disease
 Geographical morphology

4. FAI – pathopysiology of damage
CAM
 Shear forces at chondro-labral junction
 Labral tears
 Chondro-labral separation
 Cartilage delamination and peel off
 Osteoarthritis
PINCER
 Impaction at labral margin
 Tears and rip off

5. Treatment philosophy
Conservative
 Restriction of inciting activity
Surgery
 To restore normal roll and glide of the joint
 Excision of the extra bone from the femoral head
neck junction (cam)
 Rim trimming of the acetabular margin (pincer)
 Labrum is reattached if torn / surgically detached for
rim trim
 OPEN/ ARTHROSCOPIC/ ARTHROSCOPY+OPEN

6. The Labrum
 Increases containment / inreases stability
 Suction socket principle – creates a fluid film that
prevents close contact within the joint
EVIDENCE
 Routine repair of the labrum resulted in higher
clinical scores in studies that compared labral
repair with without labral repair in the
management of pincer-type FAI
 (Espinosa et al./ Larson et al.)

7. A case for LABRECTOMY
 Role of labrum in containment and stability in non
dysplastic hips – DOUBTFUL
 Suction socket mechanism disrupted with damaged
labrum, damaged cartilage, aspherical contour and
inflammatory synovial fluid
 Restoration of normal biomechanics in a repaired labrum
– DOUBTFUL
 Healing of labrum of limited vascularity - DOUBTFUL

8. A case for LABRECTOMY
EVIDENCE
 Sustained improvement in clinical scores after isolated
labral débridement of various patterns of labral
damage in patients without synovitis or arthritis
 (Byrd and Jones / Santori and Villar / Farjo et al/ Haviv and
O’Donnell )
 In vitro biomechanical data suggest there is nil
deleterious effect after the removal or detachment of
small amounts of the labrum
 (Greaves et al/ Smith et al. )

9. Material And Method
 10 hips, 8patients- 6males 2 females / Age 27-48
 June 2011- June 2013 / follow up 13m – 36m
 Diagnosis
 Pincer type 3 (osteophyte 3)
 Mixed type 7 ( healed AVN 2/ ?healed perthes 1/ Idio 4)
 Cam type 1 excluded from this study
 Arthroscopic labral excision for pincer/mixed FAI
 Cartilage status evaluated by OUTERBRIDGE SCALE
 Post op follow up at 1m/2m/6m/6monthly
 FU evaluated by Roles-modesly Score / Oxford Hip Score
 Hip arthroscopic instrumentation/30 deg 4mm scope

10. Evaluation criteria
OUTERBRIDGE
SCALE
0 – No damage
1- softening
2- Fibrillation /cleavage<1cm
3- Fibrillation /cleavage>1cm
4- eroded cartilage, bone
exposed
Roles–Maudsley
Score
1 = excellent, no pain, full
movement, full activity
2 = good, occasional
discomfort, full movement,
and full activity
3 = fair, some discomfort after
prolonged activity
4 = poor, pain limiting
activities.

11. Technique
Fem hd
Lab
Aet

12. Technique

13. Case 2
Fem hd
L

14. Case 3
lab
Fem hd
Acet

15. Case 4
Fem
hd
L
Acet

16. Case 5

17. DIAG PROCEDURE OUTE
SL
Results N
RBRID
GE
O
PRE-OP
RM/Ox
2M 6M 1YR 2YR 3YR
1 Osteophyte Labrectomy + rim trim 4 4/33 3 2 2/43 2/42
2 Osteophyte Labrectomy + rim trim 2 4/34 3 2 2/43 2/43
3 Osteophyte Labrectomy + rim trim 4 4/37 3 2 2/43
4 AVN Labrectomy + head
osteophyte removal
3 4/37 3 2 2/42
4 AVN Labrectomy + head
osteophyte removal
3 4/40 3 2 2/44
5 Perthes Labrectomy + head
osteophyte removal
4 4/37 3 2 3/40 3/41 3
6 Idiopathic Labrectomy + cam
removal
3 4/34 3 2 2/44
7 Idiopathic Labrectomy + cam
removal
4 4/38 3 3 3/40 2/42 2
8 Idiopathic Labrectomy + cam
removal
4 4/39 3 2 2/45
8 Idiopathic Labrectomy + cam
removal
3 4/37 3 2 2/44

18. Discussion
 The benefits of labral ‘repair’ in FAI is not clear and is done almost
empirically. On the other hand a residual damaged labrum may
continue to alter the hip biomechanics, causing continuing damage
to the articular cartilage and early onset OA.
 Labrectomy takes away one of the culprits and pain generators in
FAI, and may be a better option biomechanically. However
‘labrectomy’ alone is not beneficial in the treatment for FAI and
does not relieve pain or impingement in the presence of
pathological bone (healed Perthes, AVN).
 Labrectomy gives predictable favourable short term benefit in
pincer and mixed type FAI
 Maximal benefit is achieved in 6 months and is maintained
thereafter
 Grade 4 Outerbridge damage may not have long lasting benefit.

19. Limitation of the study
 No sportsmen in the group
 Labral pathology was not the only pathology that was tackled
 All patients had some degree of cartilage damage (outerbridge 3/4
 No cohort group of labral repair
 Follow up less than 2-3 years. Long term outcome unknown.