My name is Dr. Christopher Larson, and this talk is entitled Special Considerations for Laboral Management, Labor Reconstruction and Outcomes. My disclosures are I'm a consultant for Smith & Nephew, that is my only disclosure. Laboral Repair Pearls. Preserving the labral seal, avoid placing your anchors too proximal away from the rim. Ideally, you want to place them one to three millimeters off the articular cartilage margin. An over section without labral takedown helps to preserve the labral seal and position. There's normally a seal and hip extension flexion to about 90 degrees, but it's important to understand that there's normally loss of that seal with greater degrees of hip flexion and abduction. Distal based portals are better and I think safer. They make both anterolateral and mid-anterior portals more distal. This allows for better angle for safe anchor placement, better labral position and preservation of the seal. If the angle is poor, you can make an even more distal portal or a dollop portal, but I rarely need this. Intraoperative floral can be helpful. Safe placement of lateral anchors can be made using intraoperative floral by placing your guide above the source seal. Safe placement of anterior anchors can be done while making your guide perpendicular to the anterior rim on fluoroscopy. Always visualize the acetabular articular surface. When you're pre-drilling for your anchor, reposition if cartilage bulges and also want to make sure you do this with anchor placement. Special considerations for labral management. Excision of labral ossific fragments, ossacetabulae and labral preservation can be challenging. With regards to fragment excision and labral repair, it's my experience that the resection with a burr preserves more labrum than extracting with a blade. You can see at the video at the bottom that I'm using the burr to remove the bony fragment or the ossacetabulae, which in this case is in the sub-spine position. You can see that I'm removing the fragment while leaving the underlying labrum intact. Once you've removed this bone fragment, you can then place suture anchors on the acetabular rim and here you can see the labral repair after removal of the ossacetabulae and preservation of the labral seal with a CAM lesion noted. And there's the femoris section osteoplasty and the completed procedure. Although in the majority of cases I avoid a labral takedown, as seen here with focal anterior overcoverage, you can simply resect the rim and leave the labral chondral junction intact. When you have global or more profound over-coverage, there are challenges for labral management. This can be seen in the setting of a non-ossified rim as seen with the arrow on the left, or rim ossification as seen with the arrow on the bottom right. With regards to non-ossified rim, typically this is a case where you're gonna do an extensive rim resection, including a labral repair. And when there are larger rim resections, more than five millimeters, you can perform a focal labral takedown. Initially place the knife between the labrum and the labral chondral junction. Once you've separated the labrum from the labral chondral junction, we then excise this articular cartilage, which allows for labral advancement. Once we've finished removing this articular cartilage over this focal area, we then place suture anchors. Here's an example of a non-ossified over-coverage, predominantly anterolateral over-coverage, where a labral repair is performed. If you click, you can see the crossover sign and anterolateral over-coverage at the top. In cases where there's an ossified rim, oftentimes there's an irreparable labrum as seen here. The top left shows the posterior rim resection, the bottom left shows the inferior posterior extent on the S-tabular rim that we can access. The top right shows the anterior rim resection, and the bottom right shows the anterior inferior extent to what we can access on the S-tabular rim. Intraoperative fluoro is invaluable in these cases, and these can be very challenging. Here's just an example of the pre- and post-operative imaging. If we click, we can see the global over-coverage on the top. If we click again on the bottom, we can see an extensive anterior to superior to posterior S-tabular rim resection, as well as femoral resection on both sides. Labral deficiency, arthroscopic labral reconstruction is a viable option, particularly in the revision setting. The role for labral reconstruction in the primary setting, ossified rim or irreparable labrum, is not completely clear. Maybe when you have less than two to three millimeter width of labrum, or a severely inflamed hypertrophic degenerative labrum, you might consider a labral reconstruction in a primary setting. Does every labral deficiency need a labral reconstruction? Well, I think it might be important for cases where there's subtle dysplasia or soft tissue instability, or in a revision case with complete or segmental loss of the labrum, or failure has already been defined. But it might not be as important for highly congruent hips that demonstrate a seal interoperatively without a labrum. If we evaluate the labral seal at the time of our arthroscopy, we can do this with a hip extension and slowly placing traction. If you click, we can see the top left image. A labral repair has been performed. As we gently get traction, you can see the fluid efflux, which indicates there's a labral seal. If we click again on the top right, the labrum here has been excised, and you can see the hip slides out without evidence for a seal. And maybe that's a case where we consider a labral reconstruction. If we click again on the bottom right, you can see with traction, there's no labrum. The labrum's been excised, but in this case, there's still a seal with the fluid efflux noted. And that may be a case where labral reconstruction is less important. Labral reconstruction graft options with regards to allografts, you can consider IT band, SEMIT, perineal tendon, tibialis anterior, posterior, and some vendors have grafts that seem to hold up better to prolonged arthroscopic fluid. With regards to autografts, you can consider an IT band autograft, SEMIT, gracilis, rectus femoris, or ligamentum teres has been described. With regards to labral reconstruction pearls, measure your defects with a burr or a suture. Segmental defects are typically between 4 1⁄2 to 5 1⁄2 centimeters in length. Oversize your graft by about 0.5 centimeters or more. Tubalize the graft with vicryl suture. This holds up better to pressurized fluid. Label your snaps. This allows for ease of suture management. Use different color sutures for the most anterior and posterior anchors, and the same color for your middle anchors. Again, this helps with ease of suture management. And I prefer a shuttle technique, although other techniques have been described. Here's just a case example, a revision hip and the right hip. Here I'm performing a rim resection. After performing the rim resection, you can easily see the segmental defect, and in a revision case, I'm gonna consider a labral reconstruction in this particular scenario. At this point, I'm gonna release traction, and then I like to deal with the impingement on the femoral side first, before placing my suture anchors and preparing my graft. So here we see the impingement. Here we can see the recontouring and dynamic assessment, showing that we've gotten rid of any residual impingement, which is predominantly a problem in these cases. Now I'm placing suture anchors. This is an older technique for me. So here I've placed the same type of suture along the length of the rim, instead of different colors, more anterior and posterior, placing these anchors about one centimeter apart and as close to the articular margin as you can, without violating the subchondral bone or articular cartilage in the joint. I always place a third portal so that you have two clear cannulas for suture management in these particular cases. Now I'm placing a more anterior suture anchor just behind the native labrum. I'm grabbing one of the more posterior, the most posterior sutures and pulling it out the mid-anterior portal. So you have one suture from the posterior anchor and both sutures from the anterior anchor, which will allow you to perform your shuttle technique. In this case, we used a semi-tendinosis allograft, but I've subsequently found that a tubialis anterior allograft seems to be a better side for labor reconstruction. I'm tubularizing the graft in this particular case with the number two vicral suture. Again, allows this to hold up to pressurized fluid better. Now I'm placing one limb of my anterior anchor through one end of the graft, and then I'll place the limb that's pulled through the mid-anterior portal through the other limb of the graft. Once you have both ends of the graft secured to the most anterior and to the most posterior anchor, you can then take the graft, push it down into the cannula, and then by sequentially pulling each of the sutures, pulling the graft into the hip, and then carefully seeing the graft come over, in this case, initially to the anterior anchor, and then pulling the other suture, which allows the other end of the graft to be delivered to the most posterior anchor. Once you've delivered this, they then secure it anteriorly, posteriorly, and then it's simply like a standard labor repair. Here's a more recent example. So this is an augmentation case. You can see the arrow pointing to the significant adhesions anteriorly. After removing those adhesions and freshening up the acetabular rim, we can see we have about a two to three millimeter labral remnant. And in this particular case, I'm gonna consider an augmentation with a tibialis anterior allograft. So here you can see in this video, there's gonna be a blue suture anteriorly and a white suture posteriorly with the other sutures in between, which allows for super suture management. In this particular case, you can see the white suture up through the mid-anterior portal, the two blue sutures up through the mid-anterior portal. And as we pull on one end of the suture, that delivers the graft initially here to the posterior anchor. And then once the graft is delivered to the posterior anchor we pull on the blue sutures to deliver the graft to the anterior anchor. Now our graft has been delivered into the joint. Then you wanna secure the graft to the most anterior anchor, then secure the graft to the posterior anchor, and then use any device to pass your sutures around or through the labral reconstruction graft to secure it back to the acetabular rim. Here's our final labral reconstruction after femorosection, rim resection, and again, labral reconstruction with preservation of the labral seal. Accurate osseous mechanical restoration is important to protect your labral repair reconstruction. For CAM type FAI, your anterior correction is predictable. You can see the preoperative image on the left and the post resection option, resection on the right with an appropriate femorosection osteoplasty. Here's your more difficult AP correction with a posterolateral deformity. On the left, you can see the preoperative image, and on the right, the recontouring and acceptable femorosection osteoplasty postoperatively. When there's osseous instability or dysplasia, this needs to be corrected when present, oftentimes with osseous corrective procedures such as pelvic osteotomies, either a standard PAO, antiverting PAO, with global retroversion, and occasionally femoral-sided osteotomies. With regards to labral management outcomes, when we look at the data out of burn, initial study in 2006, looking at labral refixation versus debridement, they had consecutive groups. A two-year follow-up had better results in the refixation group than the excision group. They subsequently had a minimum 10-year follow-up with the same consecutive cohort, mean 13-year follow-up, but better survivorship in the refixation group, 78% versus 46%. We then use the same model in an arthroscopic, with an arthroscopic technique, looking at consecutive groups of focal labral excision versus labral refixation, and at 10-month and three-and-a-half-year follow-up had very similar results, with better results in the refixation group in comparison to the debridement group. We also have a follow-up study, which is yet to be published, but we have presented this with seven-year mean follow-up. The failure rate was 31% in the debridement group compared to 13% in the refixation group. Good to excellent results were 48% in the debridement group versus 86% in the refixation group. The results dropped in both groups, but the disparity was greater between groups over time, favoring labral preservation. If we look at some systematic reviews, we can see that all the studies have showed greater patient-related outcome measure improvement for labral repair versus debridement, but the overall quality of the body of evidence was low. What about labral reconstruction? Well, for primary arthroscopy, there was a study that looked at 29 patients. Most of these were females. They had a high failure rate in the repair group versus reconstruction group. There may have been a number of confounders and these results have not been reproduced by other authors and needs further study. For revision arthroscopy, and this is really our primary indication, revision labral repair had 2.6 times the failure rate compared with labral reconstruction by the same author as that noted in the primary arthroscopy group above. And another study by Bendome showed that a revision labral repair was equivalent to labral reconstruction, which has been my experience, showing that this is an appropriate technique. If we look at labral reconstruction systematic reviews, one study in 2016 showed that in primary revision cases, labral reconstruction was not inferior to debridement, but a labral reconstruction was also not superior to debridement. In another systematic review in 2019, they showed clinical significant improvement in patient-related outcome measures with labral reconstruction, low rates of revision and conversion to total hyparthroplasty. And finally, in 2019, another systematic review looking at autograft versus allograft really found no difference between autograft and allograft reconstruction for survivorship, failure, or conversion to total hyparthroplasty or revision rates, showing that both autograft and allograft are viable options. In conclusion, labral preservation appears to be superior to excision. Labral reconstruction is a viable option, primarily indicated in the revision setting or in a primary setting with an ossified rim or irreparable labrum with associated poor hip congruence and loss of the labral seal. It is becoming more frequent in my practice. A further study regarding the long-term benefit of labral reconstruction is required, in particular for the primary labral reconstruction with an evaluation of clinical outcomes and in addition, cost analysis. Thank you and enjoy the course.

labral management

labral reconstruction

labral seal

anchors

labral preservation