I appreciate the opportunity to talk to you today about my technique for acetabular labral reconstruction. These are my disclosures. The indications for this, for me, are revisions and irreparable labral tears. In a primary setting, I'll typically do this with an ossified labrum, a severe coccyfer funda, pincer deformity, or with an os acetabuli with severe labral intercalation. I have a lower threshold to reconstruct revisions in older patients. This is the problem we're trying to solve, severe intrasubstance damage or ossified labrum. With regards to my technique, there's a few principles. One is to minimize weak junction points between the graft and the native labrum or the transverse acetabular ligament. The good thing about this technique is that we don't need to measure and we don't need to cut the graft and the joint. The problem with measuring is that it's notoriously difficult, and the problem with cutting the graft and the joint is that you cut the sutures that you have put as reinforcing sutures throughout your graft. Additionally, this ensures that we've addressed all the pathology that is pertinent. This technique allows for and actually anticipates some imperfection with length measurement. We do this through several ways, and then we can fine-tune it with the length-independent graft management anchor, also known as the ligma anchor. First off, we want to do a thorough debridement. Getting down to the transverse acetabular ligament, we do not want segmental or weak junction points in the anterior superior joint or other areas of high stress. Posteriorly, this is key. It's really the front and the back that are the key. Posteriorly, what we want to do is get behind the native labrum down by the 8 o'clock, 7.30 position. Usually, the labrum is good in this area. Occasionally, it's ossified and you need to take it a bit longer, but this way, if our graft is a bit too long, we leave it outside the joint. Graft preparation is key. We need to be meticulous about this. Typically, I like to have about a 5 to 6 millimeter diameter graft, which makes compression and the seal very reproducible every time. When in doubt, we go long. As the guy at the big screen store told me, nobody ever brought one back because it was too long or too big. With regards to graft preparation, I use a fascia latae allograft, which is tubularized with 3-0 nonabsorbent braided suture, which reinforces the graft throughout with extra sutures at the end to act as ripstop sutures for the sutures that I'm going to put through the graft itself. The lateral portion of the fascia is on the outside. That is the shiny side or the portion without muscular remnants is on the outside. The typical length is about 100, but that will be variable depending on extent of pathology, patient size, acetabular size, and the status of the posterior inferior labrum. Graft preparation is done by my PA while I'm doing the bone work. This is this is actually an in-depth process that takes a while to perfect. Essentially, what we do is we'll cut it to, we'll mark the length, we'll leave a little bit extra on the ends to hold it in the graft station. Then we'll pass sutures through it, hold it on the graft in the hold, the graft station will hold it in place, and then we'll put extra sutures on both ends, run a suture throughout it, and then we'll wrap the graft again at the very end in order to put a final touch on the graft. So we end up then running another suture all the way down through the end of it. Due to time constraints, I won't put this, I won't put you through this whole graft preparation exercise, but this is what it comes out looking like, and then we will place the suture through that three times from the anterior infermos anchor to bring this into the joint. With regards to anchor placement, we want to put the sutures as close to the rim as possible. Anterior inferior, we're going to put this typically just above the junction of the transverse S-tabular ligament, and then what we'll do is pull the graft into the joint. I will sometimes put all my sutures in all at once. More often, I'm putting them in one at a time or putting a couple of the front ones in and then doing them one at a time. The workflow here is that once we have our sutures in place through the dollop portal, we'll use an atraumatic grasper. What I use is a crab claw. I will put it where I want it, hand it to my assistant, hold it exactly where we want it, and then tie the sutures into place. Posteriorly, this is where the rubber meets the road here. We want to see where we're getting our anchor, where we need to put our anchor. The step here is that I have my graft long enough, and then I want to put my anchor about here. What you can adjust is where you put your anchor. You can also adjust where you put the suture through the graft. What I'm doing now is my assistant is holding the graft with a grasper. I'm using a suture passing device. She's holding it against the rim of the acetabulum, so I have a backstop to pull it through. I've figured out my length, placed my anchor, and then placed my suture through the graft. If your graft is too long, that's okay. You put your anchor down a little bit lower. You put the suture through the graft a little bit lower, and you tie it into place. That way, any excess graft is left outside the joint. You don't want to be too short. The next one is a ligament anchor, which we can fine-tune our sutures with. Here, what I'm doing is posterior inferior lay. I've set my length, and now what I'm doing is I put my second anchor in. If I need more tension up here, I can go through the graft a little bit higher. If I need less tension, i.e. I'm going to be a little bit short, I can pull up a little bit by placing this suture passer a little bit lower. In this one, I'm pretty close to right on. I'll go through the graft, pull it through, and then this suture then goes back around. The one that I passed through goes back around and then tied in a loop fashion so as to lock this length and tension into place. When we pull this down, then this thing's going to be very solid. I would estimate that between where we place the posterior inferior anchor and the ligament anchor, we can adjust for about 20 millimeters of length mismatch. At that point, it's just a labor repair because you've already put in your anterior most anchors, and now you're just going to put in your posterior suture. I'm going to show you an alternative way to do this anteriorly when there's good labrum anteriorly. One of the ways that you can manage this is this patient had an ossified labrum anterior superiorly and posteriorly, but her labrum was a little bit too large. So, I'm going to go ahead and do this anteriorly and then I'm going to go ahead and do this anterior superiorly and posteriorly, but her anterior inferior labrum was in good shape. We do not want to violate the ilioformal ligament down in this area. We want to never see the psoas, and so we are keeping a very good capsule and labral buffer between your graft and the joint and the psoas. What we do here is basically put this graft, we're going to put the graft adjacent to the native labrum, so you have a really nice graft interface anterior inferiorly and posterior inferiorly where there's an overlap between the graft and the native labrum. We'll pass the post suture, we'll pass through the native labrum, and then we'll pull the graft in on the articular side of the labrum remnant, tie this into place, and then proceed as previously mentioned, and that works out very nicely. So, then we want to, of course, when we're done, we want to check our suction seal, and I will say that this is a very, very reproducible technique where we can get a suction seal that looks like this pretty much every time, and so I know we show our best videos when we're doing these courses, but it legitimately looks very sealed all the way around every time, almost without fail. So, that's a good thing because we do not want labral mustaches, because if you put that graft above the joint, you're not doing the patient any favors, and you've wasted a lot of time and effort and implant costs. So, I hope this helps, and I really appreciate you guys listening, and I appreciate the opportunity to talk to you. Thank you.

acetabular labral reconstruction

revisions

irreparable labral tears

intrasubstance damage

ossified labrum