Hello, my name is Dr. Robert Parisian. I'm an orthopedic sports medicine surgeon and hip preservation specialist at Mount Sinai Health System in New York. And we're gonna discuss the management of the acetabular labrum. So these are my disclosures, multiple societies as well as journals that I'm editorial board member of and committee member of. Now, I think it's important to look at where someone is coming from when they're giving you a presentation or a discussion or a talk on a particular topic. This is my educational background as well as where I trained. And you can see at the end in the bottom there, I did my minimally invasive hip preservation surgery at Harvard Medical School. I did both open and arthroscopic hip preservation surgery. And now I specialize in predominantly arthroscopic and endoscopic hip preservation surgery. And so this is what we'll be talking about today with regards to the acetabular labrum management. So we're gonna begin by starting off with just the hip pathology and introducing the layered concept. So the layered concept was previously described by Dr. Kelly. Looked at four different layers, osteochondral layer, the inner layer, as well as the contractile layer number three, and then the neural and mechanical layer. We're really gonna focus in this discussion on the inner layer. We were discussing the acetabular labrum as it provides static stability to the femoral acetabular joint. Now a quick anatomy review of the acetabulum and the labrum. If you look, this is an on-foss view of the acetabulum. The caudaloid fossa is in the middle of the acetabulum and there is no articular cartilage in this region. This is right here. This is the caudaloid fossa. This is the lunate articular cartilage in this area here. Now, and this is the anterior lunate articular cartilage, the superior at about the 12 o'clock designated by the stellate crease. And just superior to that, you see the indirect head of the rectus femoris is attaching over here. Now the labrum wraps roughly 270 degrees around the acetabulum. And then the most inferior aspect of the acetabulum is taken up by the transverse acetabular ligament. So again, the acetabular labrum does not go circumferentially. It's about 270 degrees. And the lunate articular cartilage follows the path of the acetabular labrum. And when we look at the acetabular labrum, we look at thickness of the acetabular labrum and we'll talk more about hypertrophy and normal width and hypertrophic and how to manage these. But if you can see number three, number three, this is how we manage a labral width. So if you can see my cursor here, this is the edge of the bony anatomy, the anatomy of the acetabulum. And then it extends out, number three, extends out. And that's how you measure the labral width. And now normal width is roughly four to seven millimeters. Hypotrophic is generally considered less than four millimeters of width and hypertrophic of greater than seven millimeters in width when assessing the labrum morphology. Now the congelatable junction, this is a one to two millimeter transition zone between the acetabular labrum and the adjacent articular cartilage. Again, we call the congelatable junction. Now the acetabular cartilage is roughly 1.26 millimeters thick throughout. Now the weak zone is within this congelatable junction. Why is that? Well, if we look at the posterior labrum, the collagen fibers are actually perpendicular to the acetabular rim, which may provide some protection to the posterior labrum. Whereas the anterior labrum and the anterior superior labrum where we see the majority of these tears and congelatable delamination, the collagen fibers are actually parallel to the acetabular rim. That then allows them to be a bit vulnerable to sort of sheer stresses within the femoral acetabular joint. And now this congelatable transition zone is also made up of a variable arrangement of collagen fibers. And again, is the weak zone where we see the majority of our pathology and hip impingement. Now, again, the anatomy and function of the acetabular labrum helps to deepen the acetabulum, so the socket of the joint. It increases the acetabular surface area and helps to dissipate and distribute forces, therefore decreasing your contact pressures within the acetabulum and decreasing the contact pressures seen by the lunate articular cartilage. There's also proprioceptive and nociceptive fibers within the labrum. This is a good cadaveric analysis here by Dr. Safran and his group at Stanford where they evaluated and quantified the circumferential strain. And they really found that the greatest strains were in compressive loading of the acetabular labrum with peak strains identified in 90 degrees of flexion and combined adduction of the extremity and internal rotation. Now, this is important because this is our impingement test, flexion, adduction, internal rotation. This engages the anterior and anterior superior acetabular labrum where we see the majority of our pathology. Now, looking at the fluid suction steel, this is Dr. Kneppel and Philippon and others that performed this cadaveric analysis. And they really found that partial or complete labral resection reduced the mean distracted force by about 70%. And so these conjolabral tears really reduced the force required to distract the femoral head from the acetabulum. And when you repaired the acetabular labrum, you then restored the stability of the hip joint, therefore increasing your distractive force with an intact repaired acetabular labrum, at least in this cadaveric model. So it really speaks to the fluid seal and the suction seal effect of the acetabular labrum as a makeup of the femoral acetabular joint helping stabilize that femoral head within the acetabulum. Now, the labral pathology that we're going to discuss when we discuss the femoral acetabular impingement syndrome, normal, you can see up there at the top left, a CAM, that is a bump or an asphericity as we like to describe it about the femoral head-neck junction, predominantly in the 12 to three o'clock position. A pincer is going to be over coverage of the acetabulum over the femoral head. And then you can have combined type or mixed type impingement with both CAM and pincer morphology contributing to femoral acetabular impingement syndrome. Now, this is a great discussion of the difference between femoral acetabular impingement syndrome and the lesions that are seen as compared to the next slide, we'll talk about dysplasia. Femoral acetabular impingement syndrome, you get this outside in lesion of impingement. So the asphericity or the CAM morphology or CAM lesion with flexion and adduction, internal rotation, or even sometimes with just straight flexion if you have an anteriorly based lesion will engage the rim of the acetabulum, thus engaging with and interacting with the acetabular labrum. And then this causes some delamination or some peel back of the chondrolabral junction and the adjacent articular cartilage from the acetabular, the lunate acetabular cartilage. And then you can get this outside in chondral flap, which is really a disruption of that chondral labral junction. Now, that differs from the inside out lesion we like to consider of a dysplastic hip. And so in this hip you have under coverage of the acetabulum over the femoral head. You have a more vertical force vector so you're really edge loading that acetabular rim. And then you can see hypertrophic acetabular labrum as secondary to dysplastic conditions, although not always, and we'll discuss that later on. But in this condition you have, again, more vertical force vector, and this leads to this sort of inside out chondral flap where you get this chondral break and disruption deeper within the lunate articular cartilage, not really at that chondral labral junction as seen within femoral acetabulum impingement syndrome secondary to CAM or pincer type impingement. So again, this is the inside out lesion of dysplastic hip morphology. So this is a nice evaluation by the Anchor Group, which is looking at labral morphologic characteristics in patients with symptomatic acetabular dysplasia. They looked at 972 dysplastic hips. So dysplasia to the point that these required PAO, osteotomy, periacetabular osteotomies to correct the coverage over the femoral head. Now within these patients, 50% of the acetabular labrums were hypertrophic, as one would expect, but I bring this up because 45% of the acetabular labrum were actually normal. And so hypertrophy of the acetabular labrum is not actually universal with mild or actual frank dysplasia of the hips. You can have normal acetabular labrum with acetabular dysplasia, and actually 4% of the labrum were hypotrophic. And then they found 64% of these patients had associated labral tears. So again, 50% were hypertrophic, but just because you have dysplasia, you don't necessarily experience a hypertrophic labrum. Now evaluating the classification system, there's been several that have been discussed, identified, but again, the Anchor Group specifically evaluated the inter and intra-observer reliability of the Beckett classification. And you can see in the bottom there, section of the table one, when you look at the labrum, this is classified as either a normal, a degenerative labrum, full thickness tearing of the labrum, detachment of the labrum, or even an ossified labrum. And for hip arthroscopists, hip preservation surgeons evaluated 40 arthroscopic videos, and they found that they experienced substantial inter and intra-observer reliability. So fairly reliable classification, the Beckett classification. Now, when we look at the overall management of labral tears, this is a nice diagram looking at repair, augmentation, debris, and reconstruction, are several of our options when we're evaluating our algorithm. We're deciding how to address these osteo-labral tears. The repair circle, as you can see here in this diagram, is much larger than the rest. It's because repair really takes up the bulk of our management of acetabular labrums, especially in the primary setting. And I will get into the indications for augmentation and reconstruction, and more of a further description of what those are moving forward. But again, the vast majority of the acetabular labral tears and contralabral junction delaminations and wave signs that we're dealing with are really gonna be treated with a labral repair. So labral repair, what goes into labral repair? Well, you prepare the acetabular rim. You can see that in the top left photo here, or arthroscopic image. You prepare this with a burr, and you're really preparing for anchor placement and allowing for a bony bleeding bed and a flatbed of the acetabulum to place your anchors. You wanna be careful not to over-resect because if you over-resect too much of the superior lunate cartilage or width, then you might have decreased superior lunate articular cartilage for articulation of the femoral head. And just bearing in mind that for every one millimeter of resection of the pincer or your acetabular rim, you have a one-to-one degree change in your lateral center edge angle. Now, suture anchors can vary in materials and designs. I prefer to use an all-suture anchor. It's a small drill hole, 1.8 millimeter, and I use a knotless suture device. And again, there are various suture techniques, a simple loop, base refixation, or an inverting suture if you may have an inverted labrum, and we can discuss that as well moving forward. Again, the goals are to re-establish the labral base. You wanna stabilize the chondral labral junction, and you're really looking to restore that suction seal that we discussed earlier. Looking at tenure outcomes, comparing labral debridement compared with repair. Dr. Philippon evaluated this, and they found that in their analysis of tenure follow-up, that hip arthroscopy for FAI, ephemeral acetabular impingement, with either a debridement or a repair, resulted in significant improvements. And those patients that had higher rates of conversion or increased failure rates were those patients that were older, those patients that were treated with an acetabular micro fracture, which is subchondral drilling to stimulate some bone marrow egress and bone marrow element egress to help lay down some fibrocartilage because of a cartilage defect. And then those patients that had less than two millimeters of joint space preoperatively had portended to worse outcomes, really showing that the quality of the articular cartilage of the acetabulum was one of the main contributing factors to outcomes, regardless of whether it was a debridement or a repair of the acetabular labor. Now, this is a nice description of why you wanna be careful when you're going to be doing a acetabular osteoplasty secondary to pincer impingement. So if you look at A, A on the left, this depicts a dysplastic acetabulum. So you have small articular cartilage and fossa, whereas B is the control. So this is normal. This is the lunate articular cartilage here, 270 degrees. And this is the cartilage fossa here, dysplastic, normal. Now it's subtypes for deep acetabulum. So a pincer acetabulum or a deep acetabulum. Subtype one for deep acetabulum has a larger anterior and posterior lunate articular cartilages, but they have a normal fossa height and width. So the cartilage fossa is normal in width and height. Subtype two, you have a large cartilage fossa and you have normal anterior and posterior lunate articular cartilage and a smaller superior articular cartilage length. So in this case, if this is a pincer type impingement, you have to be very careful with regards to your remry section here or your acetabular plasty, because you're gonna create a scenario in which you have very little lunate articular cartilage for the femoral head to articulate with. This scenario may require a reverse PAO. That's for later discussions and other topics, but just bring this up to bear in mind that just because you have pincer impingement, you really wanna evaluate that lunate articular cartilage and cartilage fossa morphology before proceeding with an acetabular osteoplasty or rim trim of a pincer impingement. So now there is a arthroscopic intraoperative video. This is preparing the acetabular rim. Again, you're not taking a huge resection here as I prepare the rim of the acetabulum for preparation of anchor fixation. Just superior or to the left of the screen here, that's going to be the proximal capsular leaflet that is behind and being protected by the sheath of my bur. And then closest to us or to the right, that is going to be the acetabular labrum that you can see there. So again, doing a careful debridement and burring of the acetabular rim to prepare for labral anchor placement. And now here we are placing anchors within the, I place my anchors anterior to posterior or medial to lateral, and it helps for suture management. Now, this is the modified mid-anterior portal here. I'm going to use a suture retriever, come down, retrieve my sutures, and then I continue drilling from the distal interlateral portal for a better trajectory onto the acetabular rim. This way, I do not violate the lunate articular cartilage when drilling, because when you drill from the dala portal, again, the distal interlateral portal, you can see here your trajectory is such that you do not violate. Now, that's a little mallet that seats the drill guide, and then you drill within the acetabular rim, making sure you're not drilling into the lunate articular cartilage here. We're not, because we have a nice trajectory from the dala. The anchor then is placed and malleted into place. Again, this is a small anchor insertion site, about 1.8 millimeters. The drill guide is then removed once the anchor is seated, but the drill guide remains in the distal interlateral portal cannula. The suture retriever then comes to the modified mid-anterior cannula, is then retrieved, and then snapped to the drapes on the external aspect of the patient. We do this in sequential fashion to place all anchors for time management and efficiency when doing an acetabular labral repair. Now, you can see, here's the third anchor being placed. This is more superior and superlateral, working our way back laterally based from placing our initial ones. Again, superior and superlateral. You can see the wave sign there on the acetabular lunate articular cartilage. Placing the third anchor sequentially, you're going to see the anchor come down, be seated again right there within the 1.8 millimeter, drill a hole within the acetabular rim. It's being malleted into place. Once again, once that is seated appropriately, the drill guide will be removed, but it will remain within the cannula of the distal-anterior lateral portal. Suture retrievers coming to the modified mid-anterior portal cannula to retrieve those sutures for appropriate suture management. Again, this is going to be snapped sequentially on the external surface of the patient on the drapes. Then we come in and place our final fourth anchor to really address this superior and anti-superior acetabular labral tarrant and conjal labral delamination and wave sign that we see. Again, a mallet is going to seat this drill guide appropriately, and then we will drill through the drill guide, taking care not to disrupt the lunate articular cartilage. Again, that dala portal really provides this nice trajectory so that we're not at risk of violating that lunate articular cartilage, and we can still place the anchors on the rim of the acetabulum to achieve an appropriate acetabular labral repair. Then we proceed with our closure from lateral all the way to medial for, again, appropriate suture management so that we're not entangling our sutures, we are not getting in the way of our repair. We're going to place that on the middle. We've already placed now two sutures circumferentially from lateral to medial, and now we're in that third anchor here, which is the second anchor that we placed, because again, we placed medial to lateral, then we repair lateral to medial. Now we are repairing, this is our third repair suture, but it's actually the second anchor that we initially placed. We use this low-profile suture passing device that is crescent-shaped. We go between the acetabular rim and the acetabular labrum, pass that through and deliver it to itself and grab it on the other edge. Now when you pull through this repair suture, you want to be careful it doesn't get looped, because you can see here that it gets looped, so you do not want to pull it all the way through. You want to be careful and have care taken that you identify this. Then you can now place your suture retrieving device through, unloop this repair suture, pass it through. Now with the repair sutures that I utilize and anchors that I utilize, this is a knotless suture technique. This one suture slides and they pull it out, there's a looped device. You place the blue repair device through the loop and then now you shuttle it through. You'll see that we're shuttling it through, now you're going to have the repair suture is shuttled through the knotless mechanism and you're tensioning and pulling this through the modified mid-interior. Now final tensioning you want to do in line with how you drilled. So now we come down with our suture retriever, we remove this repair suture from the distal interlateral portal because this is how we placed, this is how we drilled that anchor. Now we do final tension right here and you can see the tensioning of that acetabular labrum from the stain portal in which we drilled from. Now we're going to come down and cut flush to the anchor insertion site here. And again for suture management, the sutures are unsnapped now on the external aspect. We come down through the distal interlateral portal, retrieve the repair suture which is the blue suture. This once again externally now outside the hip is being placed within the low profile suture crescent shaped suture passing device. That now is going to come through the distal interlateral portal. It's going to be placed between the acetabular labrum and the acetabulum. Now with CARE trying to capture some of that delaminated articular cartilage there and really trying to stabilize this acetabular labrum for this outside in lesion. Remember we said that with an outside in lesion you can have disruption of your chondral labral junction which is exactly what we hear and with a little bit of a wave sign in the superior and superlateral aspects of the acetabular cartilage. Again you have a loop when passing this through so we identified this and we were able to unloop this suture with the suture retrieving device. We will now, I will now go in and grab the looped end of the knotless repair mechanism, pull that to the distal interlateral portal, place the repair stitch through that looped end and then we will shuttle by pulling through that one suture that is remaining within the modified mid-interior portal and you can see us shuttling through here and this again will be our final fixation. Now this is, once again, this is the first anchor that we placed but now this is the last anchor that we utilized for repair. Without full tensioning here we now pull back through the distal interlateral portal because again you want to do your final tensioning and we adjust the positioning here too of the loop for appropriate spacing and then now we do our final tension to the distal interlateral portal in line with the portal in which and the angle in which we drilled. Again now we'll come down and we'll cut flush to our anchor and to the acetabular rim. You can see this is a very efficient technique here when repairing the acetabular labrum, placing the anchors from medial to lateral and then repairing back from lateral to medial. You can see that this acetabular labrum is well adhered to the acetabular rim. The chondrolabral delamination as you can see here in the superior and superlateral aspect has been well stabilized to the acetabulum and we do not have a full thinness focal chondral defect within the lunate articular cartilage. We do not need to address that. Now we probe the acetabular labrum demonstrating complete stability of this once torn chondrolabral junction and then the chondrolabral delamination here in a wave sign. We no longer have a wave sign because you have a stabilized acetabular labrum which is also stabilizing the lunate articular cartilage at the chondrolabral junction which is again if you remember from the prior parts of the talk that is the weak zone so you can see a fully stabilized acetabular labrum. Now we are removing traction and you're going to see the recreation of the suction seal. As traction is removed, the femoral head is now reducing back within the acetabulum and then you have appropriate suction seal and distribution of forces, increased surface area of the acetabulum that's being created by this repaired acetabular labrum providing an appropriate suction seal. So outcomes. There are many, many outcomes studies that have been done. I just chose these three because they're well done and they look at high-level athletics and athletes and so return to sport was what 94% and 88% for recreational and high-level athletes respectively with Dr. Noh's group. When looking at baseball players, professional baseball players, 95% of them returned to sport and they had a mean career length of about 3.6 years after they returned. And finally looking at professional football players return to play, about 87% of professional football players are able to return to their sport following hip arthroscopy addressing acetabular labral pathology for hip impingement. And again as we discussed before, we mentioned the hypotrophic labrum, again mostly considered less than four millimeters in width of that acetabular labrum and the jury is still out. So Dr. Noh and his group found inferior outcomes with acetabular, with a hypotrophic labrum versus repair of a normal size labrum and Dr. Noh and his group found similar outcomes between those cases where you repaired a normal size labrum and those cases where you repaired a hypotrophic labrum. So again we need further study and further evaluation with regards to the appropriate management of hypotrophic labrums rather than simply going to a labral reconstruction when you encounter a hypotrophic labrum. Now evaluating borderline acetabular dysplasia. Now this is a nice five-year follow-up study, systematic review with minimum five-year follow-up looking at those patients that had acetabular labral repair that had borderline or mild dysplastic features as defined as a lateral center of jangle less than 25 degrees and typically we define acetabular dysplasia or borderline acetabular dysplasia with a lateral center of jangle either between 18 to 25 or 20 to 25 degrees and in this evaluation they found that patients with a lateral center of jangle less than 25 degrees demonstrated satisfactory clinical outcomes, high patient satisfaction and significant post-operative improvements in PROs at follow-up ranging from a minimum of five years but up to five to ten years. And so we discussed the wave sign, right, so again the wave sign is a delamination or a peel back of the lunate articular cartilage when you engage the acetabular labrum with that outside and CAM type of impingement and this study was to discuss how to manage how to appropriately manage the wave sign because many times you do not have a discrete acetabular labral tear you actually have delamination. So here you can see you have delamination of the superior and superlateral based lunate articular cartilage here then you do have a tear in this more sort of inter-superior acetabular labrum where you have that chondrolabral junction separation as an outside amnesion but this other region the superior and superlateral aspect you do not have a chondrolabral junction separation you actually have delamination of that lunate articular cartilage and that is the wave sign. When you push down on the acetabular labrum you can see some bubbling and almost a wave of that delaminated articular lunate articular cartilage here within the acetabulum with again that is peeling back as the labrum is engaged by the femoral head neck junction with the CAM lesion and then you can see the acetabular labrum has been prepared for repair of the acetabular labrum. Now again back to the treatment of the wave sign that was just demonstrated there they found that by stabilizing the chondrolabral junction even when you do not have a discrete tear or separation between the between the acetabular labrum and the adjacent articular cartilage just when you have this chondrolabral wave sign with delamination if you stabilize the chondrolabral junction and perform a femoral osteoplasty you can experience satisfactory outcomes just by stabilizing the acetabular labrum and the articular cartilage in the setting of a wave sign. Now the Everett acetabular labrum this is another anatomic variation that has been described in the literature this is a nice study that looked at the management of this and they discussed the Everett labrum and inverting that native labrum as a type of management of an Everett labrum. And so what does that look like if you look at a that yellow stars on the acetabulum that is that is a labrum there that was encountered as a normal variant and you can see that it is not on the rim of the acetabulum it is actually looks more like a glenoid labrum as compared to an acetabular labrum because we know that the acetabular labrum is really confluent with the adjacent lunate articular cartilage forming one structure whereas this is an everted labrum there is a cleft between the acetabular labrum and the lunate articular cartilage and it's really not sitting on the rim so you don't have the normal fluid mechanics in steel that you would have in a typical you know thermal acetabular relationship. And so if you can see here this is my case of an everted acetabular my case of an everted acetabular labrum this is clearing out the acetabular rim for preparation for suture anchor placement the care is taken not to disrupt the acetabular labrum you also do not want to resect too much proximal capsule so that you can still have that proximal capsule available for repair of your capsule following the procedure and I'm just using an arthroscopic radiofrequency device carefully and efficiently here to clear space for anchor placement and then if you can see to the right you do have that everted labrum that is not fully covering and fully stabilized to the rim of the acetabulum and this was specifically in this patient was involved in the superior and superior lateral aspect of the acetabulum where you had this everted labrum. Now I'm shaving with an arthroscopic shaver gently shaving partial aspects of this proximal capsule leaflet again to create appropriate visualization for anchor placement for labor repair. Now, probing, you can see the everted acetabular labrum here. You have a cleft between the acetabular labrum and the lunate articular cartilage right there, the cleft separation. That is an everted labrum. It's not sitting on the edge over here on the anterior superior aspect of the acetabulum. You do not have an everted labrum there, but you do have an acetabular labral tear, again over here noting the cleft and the everted acetabular labrum here. Not a complete wave sign, although a bit of a wave sign there. You can see the bubble and the delamination that you do have of that lunate articular cartilage, but you do have this cleft here and this everted labrum, where the labrum is not seated and positioned appropriately onto the rim of the acetabulum. And now for the labral fixation of the labrum within the anterior aspect of the acetabulum. It was placed in a typical fashion, but now for this portion where the acetabular labrum is everted, you place the anchors on the rim of the acetabulum, much like you would for a guanoid bank art repair or a superguanoid labrum repair. You place the anchors on the rim of the acetabulum, because the intention here is to invert, you want to invert this acetabular labrum, to again restore the normal biomechanics of the femoral acetabular joint and restore that suction seal. This anchor is being placed, as you can see, this is with a curved guide on the rim of the acetabulum, with preparation for inversion of this acetabular labrum, and the anchor is seated. The guide is removed, and once again from the modified mediterranean portal, a suture retrieving device retrieves the sutures and the sutures are snapped, and again replacing anchors from medial to lateral. The second inversion anchor is going to be placed again on the rim of the acetabulum, this is once again specifically for an everted labral anatomic variant, when the intention is to invert the labrum to recreate that suction seal, and just because of the anatomy of this acetabulum, I elected to use a curved drill guide with a flexible drill pin. And once again that is seated on the rim of the acetabulum. The blue repair suture is then shuttled with a suture repair device, and you can see it's through the conjugal labral junction to help stabilize that lunate articular cartilagin wave sign that you experienced. This is then retrieved from within the femoral acetabular joint with the intent of inverting this acetabular labrum and stabilizing this lunate articular cartilage delamination or peel back. There is a loop, and so now this is unlooped with the suture retrieving device. Now that has been fixed, the second inverting suture is now passed and then shuttled in the locking mechanism and you're going to see that the blue repair stitch is going to be shuttled through and you're going to see inversion of this acetabular labrum so that it now is seated on the rim of the acetabulum providing appropriate fluid mechanics as well as increasing the volume of the acetabulum and distributing forces appropriately. Now again you want to do final tensioning through the distal interlateral portal so that repair suture is going to be pulled through using a suture retriever through the distal interlateral cannula portal for final tensioning. Demonstrating acetabular labral inversion onto the rim of the acetabulum. And as we've seen before, the remaining anchors and the repair suture is shuttled between the acetabulum and the acetabular labrum, retrieved from the femoral acetabular side of the joint for repair and stabilization of this anterior acetabular labrum. And final, fixation again, repairing the acetabular labrum from lateral to medial, although the anchors are placed medial to lateral for appropriate and efficient suture management. And then a final view of the invert acetabular labrum on the rim of the acetabulum. Whereas prior to the labral repair, it was everted, you also have stabilized anterior and anterior superior acetabular labrum. So now we move on beyond repair. We're going to discuss labor reconstruction. So labor reconstruction first described by Dr. Philippon in 2010 indications, roughly less than one to 3% of primary settings. So again, labor reconstructions are being used predominantly in the revision. You'd have an irreparable labrum. You have an ossified labrum therefore it is irreparable as well. It's a fairly hypoclastic labrum and again, mostly in the revision setting for labor reconstruction. I utilize a posterior tibialis or anterior tibialis. You can see here on the graft prep and sutures are placed whip stitched. I use fiber loop sutures on either end and that is going to be for suture management for the management of the graft and passage of the graft through a pull through technique. This demonstrates the acetabular rim has been prepared for reconstruction. There is an irreparable acetabular labrum. That is a poster lateral portal that has been placed. That is going to be where I pull the anchor through, rather the graft through. This is going to the first anchor that I am placing. And then I will then place the graft inferior to this at the, so as you for with a push-lock device for the person, but this is actually going to be my knotless mechanism anchor that I'm going to be placing around the rim. And you can see, I have placed all my anchors around the rim, leaving that most interior or medial aspect of the acetabulum free for my initial anchor placement, but the anchors for the labor reconstruction have been placed. All of the anchors have been pulled out through a proximal mid-anterior portal right here. This is the proximal mid-anterior portal. And these are being snapped sequentially outside of the hip, as you can see here. So you have the interlateral portal, traditional interlateral portal. You have your modified mid-anterior portal here. This is your distal interlateral portal, your poster lateral portal here. This is where the graft is going to be pulled through. And then for suture management purposes, this is the proximal mid-anterior portal. So the graft is going to be placed through the, we'll look on this one here. If you look to the right, the graft is going to be placed through the modified mid-anterior portal. I'm going to be viewing through the interlateral portal here. The graft is then going to be shuttled through, pulled through via the pull through technique to the poster lateral portal, that is going to place the graft down within the femoral acetabular joint. And it's going to, and so it will be out of the way so that I can visualize. Then the sutures are then going to be taken from the distal interlateral portal, sequentially passed around the graft and then tensioned. And so this allows for appropriate suture management when you utilize this proximal mid-anterior portal. And you can see the graft has been pulled through, has been fixed medially or anteriorly and pulled through the poster lateral portal there. And now the graft is now lying within the femoral acetabular joint. You have appropriate visualization. You can see all the sutures that are coming out through the proximal mid-anterior portal. These sutures are then going to be passed circumferentially around the graft and tightened via the same knotless mechanism that we discussed earlier. And then now you hear, you can see a 270 degree acetabular labral reconstruction with a posterior tibialis autograft, I mean, sorry, allograft all the way back through, pulled through the poster lateral portal, the last anchor is tensioned and then that is cut. So this graft does not need to be measured because you have enough graft during your pull-through technique. This graft is sitting directly on the acetabular rim because all of the anchors were drilled through the distal anterolateral portal. And then you had the medial anchors that were drilled through the modified mid-anterior portal and the final anchors posteriorly were drilled through the poster lateral portal or rather laterally through the poster lateral portal. And so looking at acetabular labral reconstruction, a review of cadaveric studies, they found that labral repair or an intact native labrum was biomechanically more superior than labral reconstruction. So again, the labral repair of a native acetabular labrum or an intact native labrum was biomechanically superior to a labral reconstruction. So really saying that in a primary setting, attempt to repair the acetabular labrum when at all possible. And really the labral reconstruction should be utilized for those cases where you have an irreparable acetabular labrum. But they did find that when you did perform a reconstruction, you are able to restore the acetabular labral biomechanical properties, which is then superior to a complete labral excision. So in the face of an irreparable acetabular labrum, yes, it is appropriate and indicated to perform an acetabular labral reconstruction as you are able to restore those biomechanical properties. And this is better than excision of the acetabular labrum alone as it restores the suction seal. Now, again, there has been much data out there discussing the primary circumferential acetabular labral repairs that Dr. Wolfram's colleagues have described, and their conclusions are that a primary circumferential reconstruction is a viable treatment option with promising short-term outcomes, hips that demonstrate moderate or severe labral damage. Now with primary repair, I would say that we still have a paucity of data and there's evolving literature. We still need additional level one or two studies to fully understand the appropriate indications in the primary setting for a labral reconstruction. Now looking at labral augmentation, again, this is described by Dr. Philippon, and these are patients who underwent a labral augmentation, which means preservation of macroscopically healthy native labral tissue. So a labral reconstruction with allograft was performed on top of and incorporating native labral tissue that was deemed irreparable. This is an augmented repair. And Dr. Philippon then found in patients with previous procedures and augmentation technique with preservation of the native healthy labrum that was deemed irreparable at the time, resulted in significantly better outcomes as compared to a segmental labral reconstruction. But again, with labral augmentation, I think that there is still a paucity of data, we have evolving literature, and we need some additional level one or two studies to help guide us with regards to labral augmentation. So back to our diagram, again, the vast majority of labral management should and is performed via labral repair, as we have demonstrated with positive clinical outcomes and patient reported outcomes. But there is a role for labral reconstruction, labral debridement, and labral augmentation when appropriate. And the literature is still evolving in this regard. So I want to thank you again for listening and the opportunity to discuss the management of the acetabular labrum.

Dr. Robert Parisian

orthopedic sports medicine surgeon

hip preservation specialist

acetabular labrum management

hip pathology

labral repair techniques

surgical reconstruction

acetabular labral pathology