This is Dr. Michael Banfie from the Cedars-Sinai Orthopedic Sports Medicine Department, and I'm going to be continuing our lecture series on the ANA Hip Surgical Toolkit, focusing on the central compartment and that of labral repair of the hip. My disclosures are on the Academy website. And first I'll begin with the discussion of labrum, and as we are all aware, it's a fibrocartilaginous rim overlying cartilage, strongly fixed to the transverse ligament inferiorly, so it's not truly a circumferential structure, and it's triangular in cross-section, widest anteriorly as well as superiorly. You need to make sure to realize that there are these normal recesses, both posteriorly as well as anteriorly and inferiorly, that can be mistaken for labral tears, but which are normal anatomical structures. Mark Philippon's group presented a very nice study published in JBGS back in 2014, where they really showed the nomenclature of the hip and how we refer to the labrum in terms of a clock face, with a 3 o'clock position being the location of the psoas notch. They also did some measurements in this area, showing that the labrum is thickest with regard to labral height, labral width, around the 11 o'clock to the 12 o'clock position. The labral blood supply is overall relatively poor. Most of it comes from the capsule, some from the bone, and there's branches of the obturator superior and inferior gluteal arteries that are supplied on the labrum that we try to re-habituate with our repairs. There also are nerve endings within the labrum, which is so important to repair as opposed to just to breed it, and also is the argument with regard to trying to perform a repair over reconstruction. These are the free nerve endings within the labrum, as well as the nerve endings in organs such as the basenic corpuscles and the raffinic corpuscles that give us position suits. With regard to labral biomechanics, we know that it deepens into the socket, increases the volume, and the hoop stresses of the labrum improve the stability. That suction seal we just saw in that video is what we're trying to recreate when we're repairing our labrum. We know that this maintains the negative pressure, which enhances the stability, but also enhances the lubrication of the hip joint. When we're doing our labrum repair, after the repair, you want to really see the suction seal in effect, and by pulling traction after you've let traction off, you can really see the hip pop, which tells us that that negative suction seal is present after our repair. It is important to discuss a few labral repair techniques, such as a circumferential suture technique, as well as a labral base fixation technique that Ben Dome, approximately 10 years ago, made popular. Labral base fixation truly is just a mattress fixation, and the thought was that you are not crushing the labrum with the mattress fixation as you would be with a circumferential stitch. We also used to think that with circumferential stitches, you had a tendency to e-brick the labrum, which would then negate your effect on the suction seal. We now know that with proper anchor placement around the rim of the acetabulum, you do not e-brick the labrum, and although biomechanical studies have shown that the mattress fixation does have a higher distraction force, clinically, there was no difference, and nowadays, most surgeons are doing circumferential stitches. Some still prefer to utilize the mattress-reliable base fixation, depending upon the size or the shape of the labrum. I do think the portals are critical when you are repairing the labrum. The traditional portals, as Dr. Berg described, the anterior, interlateral, and posterolateral portals. We have now moved to interlateral, as well as mid-anterior portals, our main working portal, but the dollop portal is very important for anchor placement, so that is the distal interlateral accessory portal, and that will really decrease your risk of joint penetration. These pictures demonstrate the dollop portal going right up to the rim and facing away from the socket, as compared to the mid-anterior portal, which you can see in the back, which is going to facilitate suture placement of the labrum very nicely, but has a higher risk of penetration of the joint if you try to drill and place your anchor in through that portal. We published a study in Arthrosky back in 2016, which again shows the angulation of the dollop versus the interlateral and mid-anterior portal. This shows a much safer angle to place your anchors in, so I encourage you all to place your anchors through the dollop portal to decrease the iatrogenic risk of joint penetration with anchor placement. There's a few anchor systems that are on the market, hard body anchors where you have to tie knots, soft body anchors where you have to tie knots, as well as knotless anchors both in hard and soft body varieties. Also variety of sizes ranging from one and a half millimeters up to three millimeters. The terminal trim nowadays have gone to the soft body anchors and the smaller the better so you have more fixation points. We also have a variety of suture passing instruments, generally following the same idea of a traditional reusable bird beak. The only issue with the bird beak or the penetrator is that it is quite large and so you worry about cartilage injury utilizing that device, but it is reusable which is quite financially reasonable. The disposable devices are quite nice however in that they are very small, but typically the sutures do not slide in these devices so you may have to have a couple of steps with regard to suture retrieval. Here are some examples of labor repair. This is utilizing a hard body knotless anchor. You can see I'm utilizing a disposable suture passer device, there's a crescent to this device. I'm able to pass the suture through the labrum, right in the labral chondrosunction, and I'm utilizing the shape of the crescent to not violate any cartilage on the acetabulum. I'm able to grab the suture tape with that same device. This particular implant, you load the implant outside of the joint and you pre-drill holes. You can see in both examples here that I have some pre-drilled holes that I'm then going to deliver the anchor into. Once the anchor is loaded outside of the joint, you're able to loop it into the joint. What you can do with this particular anchor is leave a little bit of slack in the joint because you're able to self-tension this after the fact and then lock the anchor in place. You can see that we're pounding the anchor into the bone. This is a three millimeter anchor, so it is quite large, but the nice thing about this is that you're able to do this self-tensioning. So what I'm able to do is get the proper eversion and inversion that I would like to anatomically place the labrum in the perfect position where I would like it to be. On that right-hand video, you can just see the suture sucking up into the acetabulum, giving us the perfect... construct. Here's another example. This is where we're tying knots. This is a very small anchor, 1.8 millimeters in size. I've passed the suture through the labrum, but I've also looped it through itself. So when I pull on the post, that will then deliver and reduce my labrum back to the bone. But more importantly, it also will place the knots juxtaposed to the bone, so there's no evidence of knots by the joint. That's the critical thing when you're tying knots in the hip joint. You do not want your knots by the hip joint that can break the cartilage. You want those knots all the way up by the bone. On the right-hand side, you can see that after we've done this repair, just like I showed previously, we ensured that we restored our suction seal. And then finally, this is another example. This is a small anchor, 1.8 millimeters in size, but this is an all-suture knotless anchor. And so this is one that has tape. Pretty much all of the companies on the market have some variety of this type of anchor. You want to pass that suture through the labrum, and then utilizing the delivery stitch, essentially double up the suture onto itself, and it has a tension such as a Chinese finger trap that will keep it in place. And this works out quite nicely. I would say that the one drawback of this particular type of anchor is that it only goes in one direction. So you really need to know in advance if you need to either invert the labrum with regard to how you pass the sutures. And you really need to ensure that your anchor placement is directly onto the bone. Very anterior, very posterior, you can actually drill from inside out, and then pass your sutures through. You still get an excellent repair this way. That way, you don't have to worry about violating the cartilage and getting your anchor right on the rim. And just like I've showed previously, you can then let the traction down, ensure that you like your suction seal, and then verify that you have that negative pressure by popping the hip ever so slightly back out. I do think that it's critical to perform a very good femoral osteoplasty after labor repair. We have good data that shows that femoral osteoplasty is critical to achieve good results over two years. Encapsular closure is also very important. Ensure that you do not develop adhesions. And our studies really support labor repair. This is a randomized controlled trial between labor and bereavement repair. And you can see that the hip outcome scores for activity and living, as well as sports, are significantly improved with the repair over to bereavement. And there's durability of the repairs. This is a nine-year follow-up performed out of the male group that showed significant improvement in all PROs up to nine years. And looking at athletes in a similar cohort, by eight and a half years, they showed the improvement in the hip outcome scores, the Harris Hip Score, as well as the Tagnet Scores. This is a study looking at athletes as well, where they compared to bereavement to labor repair. And again, labor repair showed a decreased conversion to total hip arthroplasty at long-term outcome. So in conclusion, in the property of a patient, labor repair and re-fixation has excellent outcomes. We need to ensure that you're recreating the suction seal so we can improve the biomechanics of the hip joint. I do think that in setting up an irreparable labrum, we should try reconstruction over to bereavement. That will be a topic for another lecture in our series. Thank you very much.

labral repair

hip surgeries

suture techniques

joint stability

clinical studies