Thank you Shane. Good talk. Next up is Dr. Alan Zhang from San Francisco. He's going to share with us how he achieves the optimized labral repair. All right. Thanks for the opportunity to present today. Our disclosures are online. So I pretty much wanted to summarize everything I know about labral tears in six minutes, and I came up with six tips. So we're going to kind of go through these rapidly. The first one is locate the tear. So this is part of your pre-op planning with the MRI and other imaging and your diagnostic tests. But when you're going into the joint, you want to make sure you do a thorough diagnostic scope to really assess where the pathology is. And this can help you plan in terms of your portal locations, your trajectory, your anchors. In this case here, this is more of an anterior tear where the superior part of the labrum looks to be intact, and the pathology is mainly on the anterior portion. So here we kind of perform a directed anterior repair and left the rest of it alone. In this next case, this is more of a posterior tear. In this view, we lift our camera looking from the MA portal, working through the AL portal, and here the tear is more isolated in the posterior part. This is much less common than an anterior tear, but it can happen with various mechanisms like a traumatic posterior dislocation. And here we did a posterior repair. And then more commonly, you may see a pan-labral tear and a very severe FAI lesion in which we performed a pan-labral repair with five, six anchors going circumferential most of the way around the labrum. So based on where the location is, you kind of can plan your trajectory and where you want to go with your anchors. Next is to make sure you recognize the cause of the pathology. So I really like the paper by Omar Maydan in AJSM where he described the outside-in lesion. So this is the most common thing that we're going to be scoping for FAI, large CAM lesion where the CAM pushes the labrum away from the cartilage and you've got this shear force in a chondral flap. So this is commonly seen when you're going in to scope a large CAM lesion. You can see here the labrum, full thickness tear, away from the chondral labral junction with the cartilage flap. On the other hand, you want to make sure you're not missing some of these dysplastic lesions that are inside-out lesions where there's an instability component and there's a shear force. And in this case, the chondral labral junction remains intact, but then you've got a tear essentially farther down into the articular cartilage area. So here we're probing this as we're repairing it, and we're seeing that the chondral labral junction looks to be fine, but then the tear is actually extending through the articular cartilage. So it's important to recognize these pathologies in terms of mindfulness of how you're treating the dysplasia or borderline dysplasia. Tip number three would be to make sure you're treating any associated pathology. So these pathologies would be consistent with, like, paralabral cysts. In this case, there's a large paralabral cyst, and here it's right in front of us, so I just decompressed it. I really don't have evidence on this. And just like in the shoulder, like slap tears, perhaps you could just repair the labrum and leave the cyst alone. But if it's kind of sitting there, I like to try to decompress it just to make sure we get that out. If you have areas of labral calcification, these are usually in the labral capsular recess. And then if it's sitting right there, I like to make sure we clean this up. You can kind of ablate it with the RF, get that sheath open, and then come in here with your shaver and just clean all that up afterwards. And then these lesions, you can definitely see if they're large pre-op and post-op, you can see a big difference on your X-rays. And in some patients, it can be pretty symptomatic, similar to calcific tendonitis of the shoulder. And then if you have any paralabral ossicles, such as os acetabuli, if you try to repair a labrum on top of it, it could be unstable for your repair. So typically, as long as it's a relatively small os and it's not going to affect your stability or center edge angle, we'll just excise these. So we'll kind of separate them from the labrum and then remove the os and then repair the labrum behind that. And then if you have a large rim fracture where it's unsafe to remove it, then sometimes you can fix this. This is less common to have a large lesion, but we've done that as well. So we've talked about some of our methods for treating some of these paralabral findings and ossicles in our study a couple of years ago in arthroscopy. Now, tip number four, you want to perfect your technique. So this one, there's quite a large range of ways to repair a labrum. So my personal preference is I like to use a small, flexible anchor. So I like to use two portals for my hip scopes. And then this is a video of how we do our technique where we're drilling with a flexible anchor, and then we pass the suture. I usually use a loop configuration. And then I do like tying knots, so then that way I can adjust the tension a little bit more precisely and make sure I have it where I want it. But there's many ways of doing this. There's many choices for the types of anchors you want to use, knotted versus knotless, hard body versus all suture configurations and placements. So for this, you really want to just kind of test what's most reproducible for you, most efficient for you, and make sure you have a good technique going in. And in terms of choices, again, hard versus all suture, flexible versus straight. In terms of the knotless anchors, some people don't like to tie knots. There could be a little bit of a learning curve in terms of making sure you prepare your surface to make sure you can find your drill hole. So that part sometimes can be a little bit difficult. And then in terms of proper anchor placement, you want to make sure you avoid iatrogenic injury. So we're always viewing as we're drilling. You want to make sure you have a good view as you're drilling your tunnel to make sure there's no perforation of the articular cartilage underneath. Similarly, with the anchor going in, you want to make sure that's safe as well. Sometimes you could take a floral shot just to make sure that your drill bit is not going along the parallel into the joint space there right underneath the cartilage to make sure that you're safe. Suture configurations, I typically do just a loop configuration. But for a more hypertrophic labrum, you could do more of a mattress configuration as shown here where you pass the first stitch in the chondrolabral junction, and then the second one you can pierce your labrum about halfway through and then grab your first stitch, and then you can tie that. Clinically, you can see that doing this configuration provides perhaps a little bit better suction seal because you don't have any sutures there. But clinical outcomes, there has been no difference in outcomes between these two techniques. Number five, you can augment your repair. So one simple way to do that is if you're doing an acetabuloplasty, just by decorticating that bone, you're already creating a nice bony bleeding surface for the labrum to heal to. Even if it's not a large pincer lesion, sometimes I'll just gently decorticate the acetabular rim like I'm doing in this video, and you're not really changing the lateral center edge angle or affecting the stability, but you can just create a nice bony bleeding surface for healing there. There has been some recent studies looking at using bone marrow aspirate to augment your repairs, especially in the setting of early arthritis. I think these are still pretty early findings that warrant some further research, but it's something to consider for the future. And then lastly, you want to protect your repair after you've done it. So you want to make sure you have a meticulous osteoplasty. There's also proper capsular management to make sure there's no instability. And then have a comprehensive rehab protocol where most people are doing protective weight-bearing for at least two weeks with or without a brace, and then early PT to prevent scar tissue formation. And then we usually restrict low-impact exercises until six weeks, running until three months, and then return of sports at five to six months. Those are my tips. Thanks so much for your time. Thank you.

optimized labral repair

pre-op planning

diagnostic scope

pathology

surgical technique