8/18/15 ARTHROSCOPIC FASCIA LATA ALLOGRAFT RECONSTRUCTION: TECHNIQUE AND EARLY RESULTS DOMINIC S. CARREIRA M.D. ASSISTED BY RYAN ENDERS FORT LAUDERDALE, FL 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. 1 8/18/15 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! 2 8/18/15 DEFINE LABRAL INJURY Hypoplastic, Complex tearing, Extensive bruising COMPLEX LABRAL TEARING DEGENERATED AND CALCIFIED LABRUM 3 8/18/15 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. 4 8/18/15 Based on the mHSS, the overall failure rate was 11%. EARLY OUTCOMES 90 80 70 60 50 40 30 20 10 0 HHS ADL HHS Gait HHS Pain Tegner SF-12 HOS ADL iHOT-12 HHS Total SF-12 Physical PreOp PostOp 1 YrMental PostOp 2 Yr POINTS OF COMPARISON 11 5 8/18/15 ALLOGRAFT ITB RECONSTRUCTION White, accepted for publication, J Arthroscopy 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) 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 6 8/18/15 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 Right Hip Portal Placement MAP Isosceles Triangle 30º ADP ALP ACCESSORY DISTAL PORTAL Direct needle localization Through capsulotomy 7 8/18/15 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 ALLOGRAFT SIZING • Measure chord length of excised area (c) ⎛ c ⎞ s = 2r *arcsin⎜ ⎟ ⎝ 2r ⎠ Based on these calculations, the arc length is 1.3x chord length c r 8 8/18/15 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 9 8/18/15 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 1 0 8/18/15 ANTEROMEDIAL ANCHOR (RIGHT HIP EXAMPLE) MAP Standard 2.3mm anchor BLACK striped sutures thru ADP (blue 5.5mm cannula) AL Viewing Portal POSTEROLATERAL ANCHOR (RIGHT HIP EXAMPLE) MA viewing portal All suture BLUE striped ADP anchor placed through ALP (8.5mm cannula) Hemostat together 2 suture limbs 1 1 8/18/15 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 1 2 8/18/15 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 Multicenter Arthroscopy Study Hip • Determination of reparable v irreparable • Ideal graft material • Allograft v autograft? • Fascia lata v tendons (hamstring)? • Define injuries and their outcomes across treatment techniques 1 3 8/18/15 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. 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