Now, I want to introduce Marc Philippon to discuss reconstruction of the labrum in capital. Thank you. So these are my disclosures. So the labrum, as we know, is an important structure for the health of our joint. It's triangular, it's fibrocartilaginous, absorbs about 1-2% of the load, but truly trapping the synovial fluid in the central compartment is very important, so there's definitely now a point of preserving our labrum. A lot of work was done also previously with Ferguson, as far as the rim especially, that's where we still have the carnal damage, so it's important for hip stability, proper reception or surreception, and some of the load distribution. So that's what we're trying to achieve, try to see when we finish our labral repair, we always look at the seal, and we want to make sure that when we do our chem decompression, we don't over-resect, we just want to make sure it's good at position, at least up to 80 degrees between the labrum and the femoral head. These are some work we've done in our lab, where we look at hip fluid seal, and truly you can see at the top this sanguinous extravasation from the central compartment there, and that truly shows that this labrum is deficient, there's adhesion diverting it, so there's a role to release the adhesion and maybe augment that labrum to obtain maximum puncture of the labrum. So we also found that labral height is important, so when we do our surgery now, especially revision surgery, we look at the height, and we want to have, if possible, six millimeters or more. And again, as was said before, we're careful about our rim trimming, but that's part of the operation. Really, we want to stabilize a conical junction, so we look at what we have. If we don't have a good labral tissue, we'll consider a recon or a augmentation. So these are different options we have. We can debride the labrum, we can repair the labrum through a loop. Again, the goal is to have good seal at the end. And then recon for segmental part of the labrum deficiency, especially when there's no circular fiber left, that's what we do. But now we've evolved to preserve the circular fibers, because we believe that the circle around that surrounds both columns is important on weight bearing to preserve optimal congruency, so we just augment that tissue. So this is our algorithm. And again, there's a defect, we try to repair it, we'll do a recon if we have to, and then we'll do an augment if possible. So this is how we proceed. I like to use autograph tissue. The IT event, I think, is a great source of tissue. We evolve over the years with our technique. Now, especially with new instrumentation, it's relatively easy to do the segmental reconstruction. You place your anchor most, we like to start most medially, and then we place our second anchor, the most lateral anchor, and we use a device that easily moves the graft around and allows us to do in one step the fixation. This is an example here for an augment. You can see, again, this labrum is averted. The volume is probably less than six after we release the adhesion. So this patient was a good candidate for an augment. So this is how we proceed with debrided tissue. Again, we place the graft right. This is a right hip. You can see we place the labral tissue right behind the graft tissue, right behind the circular fibers, and then we just augment the residual tissue. Again, this is a different view looking from the top. Good coronal labral junction, but we see that it's really diminutive, especially around 12 o'clock there. So this is a great candidate for an augment. We'll sometime do our trimming a little higher. We're going to substantial region, and we just want basically place as much as possible there is actually on the face of the acetabulum, and then augment the tissue. You can see this patient actually also required a reconstruction of the capsule. There's a big hole there, and the psoas is being not supported, which can be a real significant pain generator. This is how it looks actually at time zero, native labrum graft, and this is a paper we showed for labral reconstruction at 10 years follow-up. So we know that segmental recon works really well at 10 years, good median patient satisfaction. We had 91 hips, 89 patient, good survivorship, and again, one effect predictor of success is a cartilage joint space more than 2 millimeters. The augment, again, this is looking at time zero. We're going to do it as a tissue that will really push the labrum in the face to optimize our seal. So this is actually another technique we use for capsule spacer. The same techniques that augment, but actually prevents recurrence of adhesion. We had good success with that. Now we rarely use that with the use of oral resortant to prevent adhesion. This is actually a second look for an augment. This was published in JBJS. We can see at time zero, we can see now at seven and a half years later, good metaplasia of the tissue and good function of the seal. This patient was revised for a second injury. This is histology, metaplasia, cerebral cell lining with fibrocartilage. And as far as capsulotomy, the key is to preserve the ileoformal ligament if you can. So with hard capsulotomy, it's laterally based. We know that the ileoformal ligament is a very important ligament to reinforce the capsule. So we really make sure that we preserve that. But in the case of deficiency, this is pretty significant. Look at the big holes there. So in this situation, we like to proceed with reconstruction. As Dr. Stubbs was mentioning for us, we use different technique. But the reality is we place our anchor at the proximal end, and then we do a side to side adastomosis distally. We use number two Viacryl. And that technique in our hands has been very, very, very helpful. Now with the new instrumentation we have, there's good instrumentation out there. It's very relatively easy to do side to side adastomosis. You save a step. You deliver your suture in one step. And then just do one other pass in this limb and do a great adastomosis. So we start at 45 degrees of flexion. But then we test our graft and extension. And we cycle to make sure that the graft is not under too much tension. Finally, the segment we replace with the capsule or around the source, soft tissue mass or the minimus soft tissue mass. These are real pinching the issue. In this patient now, we have good evidence that it's really helpful as far as resolving the symptoms. Again, we have some evidence from the lab that this reconstruction helped in restoring the dysregulatory stability. We compare dermal allograft versus allo- I use allograft IT. And actually, in our hands, allograft IT does better. This is clinical outcome we have. We have 90% of our patients reach MCID. For us, ADL and Osport. So the mean survivorship was five and a half a year. We have protocols important. You want to do circumduction post-op. We found that for us, protecting the weight bearing for at least 10 days is very effective. We use passive range of motion. And again, circumduction is very important in minimizing the risk of adhesion. We also now use Losartan as an adjunct. In conclusion, I think now we know that preserving the labrum is important. If you can't preserve it, just do an augmented recon. Preserve the capsule if you can. If you don't have any capsule tissue, especially in revision cases, make sure that you're prepared to do a recon because that's going to be beneficial for the patient. And have a good rehab team to help you with the recovery. Thank you.

labrum

hip joint health

surgical techniques

labral repair

autograph tissue