Hi, my name is Andy Wolfe. I am from Washington Orthopedics and Sports Medicine in Washington, D.C. I'm excited to bring you my labral reconstruction technique as part of the Anna Tool Kit Hip Edition. Labral reconstruction is something I've been doing for a very, very long time and I think is a vital piece of my armamentarium for treating complex hip problems arthroscopically. So without further ado, here is the technique that I like to use and the rationale for it. So the goals of labral treatment in any arthroscopic hip surgery are to number one, eliminate damage in pain generating tissue. Number two, to optimize the stability through restoration of a circumferential suction seal by the labrum around the femoral head. Appropriately balancing these competing aims is the key to optimizing results in hip arthroscopy with respect to the labrum. So my approach is to take a patient specific labral treatment because we know we have, in certain cases, good results with labral debridement, but that this is likely suboptimal in many patients. But there's also limitations to performing labral repairs or augmentations because you can't repair something or necessarily augment something if there's nothing to repair or augment. So, for instance, this is a patient I did a number of years ago, a 42-year-old woman with DISH, with obvious, horrible impingement as a result. In another instance, this is a different patient with substantial interest in substance cysts and synovitis on MRI. So the labral tissue you can see here is just completely swollen and inflamed and run through with cysts and synovitis. And what this looks like when we're looking at the tissue arthroscopically is that indeed it may look somewhat okay from the outside, but when we get to the inside of it, it's very angry tissue and substantially damaged and unlikely to be amenable to a simple repair as this goes all the way through the labrum. Similarly, this is another patient that I was doing a revision surgery on. You can see there's a lack of suction seal due to the hypoplastic nature of the labrum, but also due in part to scar tissue. And so what we want to see, this is the same patient after we did the reconstruction. On the left, we're looking posterior inferiorly. On the right, we're looking anterior inferiorly. What we see is that we've restored, circumferentially, a seal on the femoral head such that that was not there previously, and this was done with a labor reconstruction. This is a patient two years post-operative leave from a labor reconstruction. You can see maintenance of a suction seal with good tissue going circumferentially around the femoral head, still being sealed up nicely, well-healed in place. And not to belabor this, but what do we put in? We put in a fascia latae allograft that my PA makes in the back table. She has the world's fastest hands. And what we do is we use 3-O non-absorbable braided suture to reinforce the and then put it in arthroscopically, and we'll go over that. So what we're trying to avoid is labral mustaches or where we have the labral reconstruction that's sitting above the femoral head, so we're not restoring the seal. This does not help anyone. And similarly, we want to avoid gaps in between the native labrum or the transverse acetabular ligament and the labral graft. So we want to mind the gap, to be certain. And so for a traditional, what I would call traditional circumferential labral reconstruction, we'll go down to the transverse acetabular ligament anteriorly and posteriorly. And the way I sort of think about this is putting the emphasis on the elimination of pain-generating tissue. I think that in some cases, this is not necessarily always desirable or actually necessary, as we are sometimes eliminating good tissue that we don't need to necessarily eliminate. And so I've taken to more tailoring my treatment to the patient's anatomy and pathology, and so we can effectively perform more of a labral augmentation of uncompromised tissue anterior inferiorly and posterior inferiorly, and resection and complete reconstruction of the tissue that has damaged or is missing, damaged beyond repair or is missing or is suboptimal. And we can get good overlap between the graft and the native labrum on both ends by anchoring this and fixating it behind the labrum on both ends. So we still don't want to be short, so we need to be careful to mind the gap. And we don't want to leave pathology unaddressed. So the way to accomplish this is to choose a length of graft that is safely too long, and then resect a bit more labrum if you need to, to get a solid circumferential seal. And so we typically start with about a 90 millimeter length and adjust, rather than adjusting the graft and cutting it intra-articularly, which is a problem because we've run all these sutures through the graft as sort of reinforcement sutures, and cutting those rifts, unraveling it. What we do is tailor the resection of the posterior inferior labrum to the graft length at the end, and so we'll go through that here. So first anterior inferiorly, we have to be careful because this anatomy is variable, and sometimes it's hypoplastic with tearing extending into the transverse S-type of ligament. Oftentimes it's adherent to the iliofemoral ligament, and you have to be very careful not to violate the iliofemoral ligament or that anterior inferior area of the capsule because that separation between the psoas and the joint is very, very important. I've seen a lot of cases, revision cases, where we have that psoas tendon coming in and out of the joint and getting abraded, and that's a tough problem to fix short of a psoas lengthening procedure. So there's a lot of variability in the anterior inferior labrum as it conjoins with the transverse S-type tabular ligament, and so what we want to do is create a space for the graft to lie in behind and augment the native labrum slash transverse S-type of ligament, and sometimes this involves dissecting with the hip autotraction and inflection to make sure that we can get a good space safely without violating the iliofemoral ligament, and at times we have to be very, very careful about our dissection in order to get this right. The anchor placement, we want to make sure that we're placing the anchors as close as possible to the rim so we don't get that labral mustache effect when we're done, and in my hands I think it's important to resist the temptation to put two end anchors and then fill in the middle because you have a hard, there's going to be a hard time tensioning that length and the tension appropriately. You can place several anchors at once or you can do one at a time. I sort of take a hybrid approach on that, and then in terms of mechanically of who does what, what we'll do is we'll pass the sutures and I'll have my assistant hold the labral graft in place through the dollop portal while I tie the sutures, and we can sort of move it, move the graft around, get the anchors placed in the right way, and every time that we're tying these down, we're making the graft tension placement, et cetera, more perfect after we have the anchor in place as close to the rim as possible. We do try to manipulate the graft as little as possible so as to not damage it. And then posterior inferiorly, what we're trying to accomplish is the resecting back to good tissue, so we're looking now from the mid-anterior portal posteriorly, and we're getting back to good non-damaged tissue here at approximately the nine o'clock position. But then what we'll do is we'll burr back behind this so that we have, we're getting, we can put anchors in behind this so we get good overlap between the graft and the anchors. And we've preliminarily cut this before we put the graft in, and then we take a bit more as we find where our graft will end up. So we're going to take a bit more and burr down a bit more, and then we'll put our posterior inferior most anchor in, and so right now what we've done is we've passed all of the, we've passed all the sutures up to about the 12 o'clock position, then we'll skip to the back and put that posterior inferior most anchor in, and then work our way back towards the 12 o'clock position, so we'll do the very anterior inferior up to about 12 o'clock, and then skip to the posterior inferior and then work our way backwards. This area, the posterior inferior aspect of the S-tab is a little bit less dicey unless it's ossified or there's a coxa profunda, but typically what we'll find is that there's good tissue found below 9 o'clock, and that we don't have psoas concerns as much, we don't have any psoas concerns, and so what we're doing is we're going to burr behind the labrum for subsequent. Anchor placement, and then we're going to measure where we want to pass the suture from that anchor through the graft, and so we can adjust our tension and our length based on anchor placement, where we're adjusting where we resect the graft, where we pass the suture through the graft, and so that we can get this right pretty much every time, and then that's the posterior inferior most anchor, and then the next anchor up from that is the ligament anchor where we can fine-tune that tension. And so what this one is, is an anchor that's just above the posterior inferior anchor because the posterior inferior anchor is a bit weak because it just goes through the graft one time. This anchor, we're going through the graft and then we're going to go around it as well. And you can adjust your tension, this really locks it in, but you can adjust your tension by where you pass through the graft relative to the suture anchor so you can make it a bit tighter or you can make it a bit looser based on where you pass through the graft. You're going to pass that lead stitch around and below itself so that we end up with really sucking that graft down and locking in the tension with this ligma anchor, and that stands for length independent graft management anchor. And so the take home messages on this are that what we want to do is eliminate pain generating tissue, we want to restore the suction seal circumferentially, and it's my personal preference to consider augmenting the ends when we have good tissue there and reconstructing in between if the pathology doesn't include far anterior inferior or posterior inferior labrum. But I think it's important that we tailor our treatment to the patient's pathology and the most important thing is to make it stable, we don't want mustaches and we don't want gaps.

labral reconstruction

hip arthroscopy

femoral head

fascia latae allografts

suture management

pain elimination

anatomical boundaries