Thanks guys. So I'll talk about labor reconstructions, go big or go home. My disclosures can be found on the Academy website. So we're all familiar with the role of suction seal. This is a good video that Jorge Chala put together just showing the suction seal effect in a native labrum. You can see how hard it is to distract. When there's a segment of labrum removed, you can see that the loss of suction seal. And with a labral reconstruction or preservation, you can see that there's excellent restoration of the suction seal. So anatomic restoration or preservation of labrum, I think is critical. I think that we're all trying to achieve that goal. And I think that we have to keep in mind that if we preserve the anatomy, that we will preserve the biomechanical characteristics, and that is maintain the suction seals. We demonstrated stability of the hip joint, also dissipating contact pressure across chondrolabral junction, as well as preserving proprioceptive fibers and pain fibers, which we all think is very important. In terms of treatment of labrum, basically we have four options. We can either repair, augment, debride, or reconstruct. And the previous speakers obviously talked about repair and augmentation, so I'll talk about reconstruction. My algorithm in terms of addressing the labrum is really quite simple. I mean, on the left, you can see a good labral tissue. Whether in a primary or revision setting, I think repair is obviously the right decision for that patient. If you see a labrum that looks like this, then obviously I think you've got a couple other options that you want to think about. You can think of selective labral debridement. I think there's good studies to support that, and I think that we shouldn't overlook that. Augmentation, if there's native tissue or host tissue that's available, I would say try to use as much of the host tissue as you can. I do agree with the augmentation approach. And reconstruction, as we talked about before, if there's really no viable host tissue, then sometimes you have to reconstruct it. And so I think we've got to be ready and available to do any of these options. In my personal practice, I end up doing reconstructions primarily in a revision setting. Probably about 20 or 30 percent of my revisions will undergo reconstructions. And in the primary setting, it's pretty rare. I would say once in a while, as we talked about before, they're calcified labrum or coxa protrusio. There are good biomechanical studies looking at the segmental labral reconstruction on the fluid seal stability and contact pressure. I think the take-home point is this, is that the labral reconstruction does improve biomechanical properties better than labral tear, but certainly not as well as repairs as far as what we've seen so far. There is good clinical evidence for a segmental labral reconstruction. Mark Philippons published a number of papers on this as well as Dean Matsuda. But there is definitely an interest in terms of larger labral reconstructions or what some authors have called circumferential labral reconstructions. And I think it's really important to kind of differentiate between what is segmental and what is this either circumferential labral reconstruction. In general, I think of segmental as somewhere between like five centimeters or so or maybe five hours on the clock face. And if we're getting more extensive than that, I think that that's when we're talking about total labral reconstructions. In literature, you'll see it named a couple different names, either front to back, 270 degree, total labral reconstruction, circumferential, or my personal favorite is a ligma from Dr. Wolff. But here's an example of a 35-year-old woman. We actually did this case last week. But she has obviously a large ossified labrum. You can see that our primary concern is to address that large ossified labrum. As previous speakers have talked about, in some cases you really have no labrum left. So you're left with either to just leave it alone, is probably what we did historically, or reconstruct it. And reconstruction in this case I think seemed like a good option. Basically pass all our anchors first. And I think one of the pearls is using a curve guide. I like to go as close to the contralabral junction as possible. Suture management obviously is really important. And here you can see that once we've completed all of our anchor passage, we'll go ahead and prepare our graft on the back table, address any peripheral compartment work. And once we're ready with that, then we'll start to pass our labral graft. In general, I want to make about a six millimeter graft in terms of width. Here we're just passing our stitches from the medial most and the lateral most. I like Mike Ellman's technique of the kite technique as well. And so we'll go ahead and pass the medial side first and tie it down. In some cases you can also pass the lateral side first. But I think in the larger grass it's harder to do. And so in this case, we'll just go ahead and sequentially start to refix and secure the labrum going from medial to lateral. And in some cases you might have to actually rotate the camera. So here we've got the camera in the interlateral portal. When you want to get to that more lateral portion, I think it's helpful to have the camera in the modified interior portal as well. And so here we're securing our final couple of stitches. And you can see that this is probably a close to total labor reconstruction. Maybe depends on how you defined it. But again, I just, whatever native tissue I think is viable, I'll use it. But if it isn't, then we'll go ahead and replace it while we're there. So here we've got a finished product. You can see we've got a nice restoration of the suction seal, dissipate the contact pressure. We'll go ahead and take it off traction. And you can see that we've got a nice restoration of a seemingly reconstructed labrum. So what does the biomechanical study show us about intact labor repair or labor reconstruction? We've done a number of these cadaveric studies in our lab looking at the effects of these different interventions. In these studies we use cadaveric specimens. We go from intact, basically we'll repair the anterior superior quadrant and then we'll take the same specimen, remove the labrum and reconstruct it. We'll follow kind of the protocols as been described. We'll go ahead and prepare the rim. We'll place all of our anchors. We'll do a 270 degree transverse ligament to transverse ligament reconstruction with a iliotibial band allograft. We use a tech scan for contact pressure, contact area and force. And what we find is that the contact pressure does increase with the circumferential labor reconstruction. There's also a decrease in the contact area. And when you look at the suction seal, there is a difference in the intact state. Obviously there's a good suction seal in a native hip. In a repaired hip, also a good suction seal. With a reconstructed hip, we were not able to reproduce the suction seal in our cadaveric model. Brian White has published a couple of papers on the total labor reconstruction in a primary situation. There's two papers that I want to highlight. One is the first one where he reported good results, but he had about a 14% complication rate or revision rate in that series. And then he had a series where he compared the primary labor reconstruction against his labor repair. He found that the labor repair group had a 31% failure rate compared to a 0% on the reconstruction group. Ben has published a nice paper looking at circumferential labor reconstruction for irreparable labor tears in the primary setting. And he compared it to a match group of labor repair. Green is reconstruction. The match group is in blue, and you can see that there is some improvement with the repair group compared to reconstruction. And the multicenter arthroscopic study of the hip group, the match group, looked at the native labrum series comparing both repair segmental reconstructions and circumferential reconstructions and finding that there is essentially no difference when it looked at percentage of MCID and percentage of PAS. And this is across a series of six different surgeons. There's a new paper that's coming out that's been accepted but not published yet looking at the match group in terms of revisions, again, with treatments between labor repair and reconstruction and finding that the HOS and the modified Harris hip score was really no different. So and in some cases, I think the adhesions could be a problem for some of these labral graphs, as some of the other speakers had mentioned. And while it may be done technically very well at time zero, I think there's probably a small portion that might develop adhesions, and probably the graphs might have a role of it. But I think it's something to keep in mind. I think the question about should we adopt total labor reconstruction as a new standard in a primary setting, I think the things that I think about when I'm thinking about new technologies and adopting them is does it make it better for the patient? Is it faster for me? Is it cheaper for the center? And I think it's hard to support that at this point. At this point, many of the biomechanical and the clinical studies seem to show that labor reconstruction is comparable labor repair. And I certainly don't think that they're clinically better or biomechanically better. It's definitely not faster. A lot of these cases may double or triple the amount of operative time than a standard labor repair. And it's definitely not cheaper either. So in conclusion, the role of total labor reconstruction is controversial. There are some significant technical considerations for this procedure. The biomechanical studies seem to show that there's increased contact area and loss of suction seal. And the clinical study shows still that labor refixation remains the gold standard for the treatment of labral pathology. Thank you very much. Thank you.

labor reconstructions

treatment options

anatomical restoration

labrum preservation

biomechanical characteristics