Thanks a lot, and thanks, like I said, it's a pleasure being here. So I'm going to start it off with, in the setting of the talks we just heard, I think there's a lot of new data that's showing that there is a role for labor reconstruction augmentation, but I am going to take the side of, what's this one, these are my disclosures right here, none of which are relevant for this talk, that why should we do labor refixation? Well, the answer for me is because it works, and there's lots of data in the literature right now that demonstrates the efficacy of labor refixation. I think a lot of it is patient selection, that if we are choosing the right patients with repairable labrums, the majority of the times we're going to find that we're able to repair them quite well. In order to do it, though, it is really critical that the technique that you use is looking at ways to restore the normal function of the labrum, and so the technical aspects of it are really critical and have to be paid close attention to. I think for me there's three general approaches that I take toward labor refixation. The first is rim decompression with labor preservation, and these are what I would consider to be a stable labral tear, or when there's not a real rim resection that's required, but maybe more of a subspine, anterior inferior iliac spine overgrowth, and you really have a stable base fixation of labrum, and in that setting you can preserve the labrum and still do the decompression appropriately. The second one is the one that I most commonly use in my practice, which is capsular elevation, take care of the rim and the subspine area, followed by labor refixation, and this is usually necessary when the transition zone has become delaminated, so after the rim decompression you do have an unstable labrum and it needs to be refixed. And the third, which is the more traditional, which is based on the open technique, is detachment of labrum followed by labral refixation, and I think this is one that you might have to consider in true acetabular retroversion when you still have healthy labral tissue. So I think the general principles for me is know clearly where are the accessible areas on the acetabulum, this may be different for different people depending upon what their experience is, but predominantly anywhere from 9 o'clock posteriorly to 3 o'clock anteriorly are relatively easy to access, and as you get more inferior, either anterior-inferior or posterior-inferior, it does become a little more challenging. We have to make sure that we're putting the anchors in the proper location, we heard one talk that talked about putting it too proximal and you can evert the labrum, you really want to get as close to the acetabular rim without violating the subchondral bone, and you want to do the best that you can to recreate the anatomic shape of the labrum and restore the natural function and suction seal effect. So here's the first example, this is what I would consider to be a stable labral injury, and we can elevate the capsule, expose the prominent area of rim, we can decompress the rim anteriorly, and when we're done, we still have a stable base there, I don't think there's any reason that we have to put any anchors in this, but we still have viable tissue, and there's no real reason to detach this labrum, there's no real reason to do a labral augmentation or labrum reconstruction. The more common one is, I break it down into several steps, you want to get good access, do a diagnostic evaluation, do an interportal cut so that we can clearly visualize the rim, decompression, labral refixation, and make sure that we're appropriately treating all the associated mechanical problems. So here's the example of the typical type of patient where they have some transition zone injury from the CAM morphology, they have good labral tissue circumferentially, and we're able to make sure that the damage pattern that we see in the joint is consistent with the mechanics that we preoperatively identified. So the combination CAM and rim, you see the delamination inside the joint here, you see the erythema on the rim capsule side of the labrum here, which is from the rim, and then we need to start addressing, exposing the rim. Once we expose the rim and decompress it, because there was the transition zone delamination, this is an unstable labrum, but still functional tissue that we can deal with. So here's an example of a rim preparation, I think as we use the radiofrequency probe to take the capsule off of the rim, and we can start to see the labrum peel off, we're not frankly detaching it, but at the end, we've exposed the rim, can do adequate decompression, and we still have good healthy labral tissue, and this is the majority of patients that I see look like this. So once we've decompressed the rim, we can put our anchors in, I think if it's possible to go intrasubstance rather than circumferential, it is slightly better. It does allow us to have a better suction seal when you take the hip off traction. If you're not able to, a circumferential labral refixation I think is okay. And once you're done with this, I'm trying to show the difference of how the labrum sits with the intrasubstance passage of the suture, where you've got good placement of the aspect of the labrum on the femoral head, versus in the circumferential one where you may get a little bit of eversion of the labrum and have a bit of loss of suction seal there. And then the third approach, which is labral detachment, rim decompression, labral refixation, I think this probably is something you need to consider in true acetabular retroversion because it is difficult to resect the labrum, or you may resect it and it ends up that the labrum actually falls off. And in this setting, we can detach the labrum as was traditionally described for the open literature, do an adequate rim decompression, and then we can make sure that we have proper anchor placement as we're always doing, try to get as close to the articular surface as possible so that we don't ever at the labrum. And then if it's possible, pass the sutures intrasubstance so that we can get good restoration of the suction seal. So those are the three techniques that I typically use. I think in the vast majority of cases that I see the labral tissue is repairable and the outcomes are good. So the thought of removing healthy labral tissue and doing a labral reconstruction doesn't make a whole lot of sense for me. I think the case that Ben talked about where you do have a real profunda or a real calcified labrum may be an exception to that. Augmentation, I just haven't seen the role for it, although definitely there's more and more literature to support it. I think there are several questions that we still haven't answered about the labrum. What is the true healing potential? Can it re-tear? What happens if the labrum is not re-fixed in some of these cases? But I think we continue to evolve our techniques and as we are able to do this, more anatomic re-fixation will continue to lead to increasingly satisfactory results. And for me, the role of labral reconstruction is still very controversial. Thank you.

labor refixation

appropriate technique

patient selection

location of anchors

labor tissue repair