Well, I did look up what Donnybrook and Blarney mean, and I'm still not totally sure I understand. I think Donnybrook is a heated argument, and Blarney, I'm Blarney, right? So I'm supposed to be charming and flattering, I think. So I'll do my best. Disclosures are in the AOS program. So we know the functions of the labrum, and I won't review them all, but all together they serve to summon to a chondroprotective role, which is critical to the function of the hip, and the labrum sealing mechanisms are dependent on the fit of the labrum against the femoral head. So I think just about everything that we've ever done trying to improve our care for the labrum serves this principle. We're trying to restore the seal, whether it's repair or whether it's reconstruction and a variety of different techniques for each, we're trying to restore the seal. So we know that with an intact labrum, you get this seal. You hear that little, you hear in the lab. There it is there, nice seal. So that's what we're after with whatever technique we use. Now, when we have a labral tear, we have compromise to that seal, or potentially at least compromise to that seal. So we need to do something to fix it. Now, why restore the labrum, whether by repair or reconstruction? We've got biomechanical evidence that the labrum's critical to the function of the hip. We've got clinical evidence that we get better results with labral restoration than debridement, and common sense. The hip was made with a labrum for a reason, so it probably stands to reason that we should restore it. So when we're faced with a repairable labral tear, and I think that's where there's debate, should we repair it, should we reconstruct it, or should we augment it? So Donnybrook, it's supposed to be a heated argument, and I'm supposed to be blarney and flatter and be charming, so I think we'll see in this little debate if strength can win over flash or not. So before betting, think twice. Labral recon is not easy. It is a difficult procedure, and I think everybody would agree on that. It should be done in a setting of a high volume of labral reconstructions, and there's a lot to it, and there are a lot of pitfalls. With any of the techniques, so we want to be very good at it if we're doing it. I love labral reconstructions, and Dr. Wolf pointed that out very well. This is an example of the circumferential technique that we use, and we place all the anchors prior to insertion of the graft, and then do a knotless pull-through technique here for the introduction of the graft. These are knotless anchors, which can be pass and cinch and pass and cinch, so it's a fairly efficient technique. But we did this study looking at a consensus in JHPS, and basically there was consensus that this is a technically demanding procedure. Only 8% of the surgeons were cataloged as high-volume reconstructionists, and these were all high-volume hip arthroscopy surgeons, and there was consensus that the results in low-volume hands may not be as reproducible. It's sort of self-evident, but good to have agreement amongst our colleagues. So what about the costs? There we go. Primary circumferential ostabular labral reconstruction. This is the study Dr. Wolf cited earlier, where essentially the outcomes were equivalent despite differing groups of patients. So that tells us that different patients had different procedures done, but it doesn't tell us that one is better than the other. The results were actually the same, while the number of anchors and the cost of the allograft and the surgical time potentially all result in increased costs. So that's, as doctors, probably not our biggest concern. We care most about helping our patients, but something to consider as well. How about evidence? The long-term evidence is there really only for labral repair at this point, and it will be for reconstruction at some point, but we have a little bit of catching up to do in the reconstruction evidence. So this is where we've gotten. We've gotten a minimum five-year outcomes with labral reconstruction, with a nested match compare benchmarking against the labral repair control group, and we found that primary recon reached comparable function outcomes compared to a benchmark primary repair control group. Very similar results to what Dr. Wolf found, but actually we had slightly lower patient satisfaction at latest follow-up in the reconstruction group. In fairness, the techniques have evolved and improved, and I think that the patients in this study were mostly segmental reconstructions. Today we do a lot more circumferential reconstructions. So it's an evolving body of evidence, but at present we don't have any clear evidence that the results are better with reconstruction than with repair in my view. So repair versus reconstruction. Repair, I believe, is very reproducible. Reconstruction can be in a high-volume experienced setting as well. The repair, I think, in just about any setting is less surgical time. The costs are clearly less, and there's evidence to support repairing when possible. So there's the result of our Donnybrook. So controlled tension anatomic technique for labral repair, when possible in the primary setting, gives us a very reproducible seal of the labrum against the femoral head. We can control the tension, hence avoiding eversion of the labrum, and ultimately at the conclusion of the procedure we can take traction off and see the seal of the labrum against the femoral head and see that we've restored it securely to the acetabulum. So in terms of an algorithm for primary treatment of labral tear, primary repair remains our gold standard. Reconstruction, however, is a valid option or alternative to debridement when repair is not possible. So if we're faced with a labral tear and we have good viable tissue, repair is the first option. If we do not have viable tissue because there's a defect or it's calcified or it's irreparable or non-viable, I think we all agree that we want to achieve the sealing effect, and in that case it can be best done by reconstruction. Thank you very much. APPLAUSE

labrum

hip

restoration techniques

labral tear

repair vs reconstruction