All right. Thank you. So to continue the trend of failed hip arthroscopy, I was tasked to talk about labral deficiency. And I'm going to kind of approach this from the primary standpoint as well as the revision standpoint because that's truly what the term is from a labral aspect. We'll talk about a number of examples as we go. So illicit disclosures can be found on the website. So I want to start with this because, you know, revision hip arthroscopy, as we've heard from many giants in the field, is it's a complex thing. The indications are important. It's understandably one of those things where you don't want to be getting into the hip and not knowing what to do next. Making sure that you're there for the right reasons is critical. And there are a lot of pitfalls. So doing your thorough workup, your diagnostic injections, your imaging, getting all your tools are important before you enter this case. And I just want to caution anyone starting out in hip arthroscopy to do just that. Take on cases that, you know, you are confirmed intraarticular sources of pain. You're sure you're there for the right reasons because you don't want to get into something and take down a labrum and plan to do a reconstruction if you don't have that in your toolbox. So I'm going to throw a couple of little rapid fire. This is an internal poll of the audience type of question. So what would you do seeing these kind of cases? This is all primaries here. So this is not revision. But primary hip arthroscopy, oh, there we go, elf. The tissue itself seems fairly floppy. It doesn't seem like it can hold anchors as well. Now, could you perform a labral repair? Sure. But would it be enough? I want this to be a repair that lasts for the patient. This particular case, we've got labral deficiency. So it's a different type of deficiency. It's actually from the volume perspective. It's a very small diminutive labrum. And I think that is important so that when you see this case, you may not need to take it down. You may not need to do a reconstruction of this. But in my hands, this would be what I showed previously would be an augmentation I would add to this. I want to give this more substance and perform a kind of an augment graft that's connected to the native tissue so that the chondrolabral junction is intact. And when traction comes off the hip, you've got that native labrum pressing up against that femoral head. This here is pretty obvious. This in my hands doesn't seem like it'll hold tissue and sutures consistently. So for me, this is a takedown and give a new. And again, we're here because the patient likely has hip impingement in that particular example been done. So I want to, again, re-labrum some mobile patients, as Dr. Saffron had pointed out. Iatrogenic instability is a risk when you assess this case intraoperatively with a big capsulotomy and you don't perform plications. This particular case, what I'm going to do is also an augmentation. So again, I tend to use a 6-millimeter graft for all my augmentations because I think that's what the height is needed to give this tissue quality back to the hip. So just briefly talking about the anatomy and purpose of the labrum, I mean, it's well documented now. The stability is needed, resistance to distraction up to 66% in a reconstruction. So, you know, these studies really set the tone for what is, you know, we talk about irreparable labra. Well, why reconstruct? Well, there's biomechanical evidence, there's clinical evidence now, and it just kind of makes sense. If the hip was built with a labrum to begin with, we feel like we should put one back. This is sort of an evidence-based pearl. When we see segmental defects, you have two different kind of pathways here. With a preserved chondrolabral junction, as I showed previously, I'd recommend doing a segmental augmentation, whereas if you have a compromised CLJ, then we perform a segmental reconstruction. And again, this is just, it's a dealer's choice, majority of it will be done intraoperatively. And of course, if we have a complete defect with a compromised CLJ, we're going to do a circumferential reconstruction. So what are the indications for the labral reconstruction? So you've got segmental loss, calcified labrum, failed debridement, failed repair. Again, the goal is to provide the hip with new quality tissue because it needs it. And if you get in there and showing calcifications, you've got MRIs showing diminutive labra that's taking up that contrast fluid. It's kind of like this heterogeneous interstitial signal, they'll call it, from the radiology report. It's not going to show a nice, it's just taking on fluid during that insufflation of it. So the types of reconstructions that we can talk about, segmentals and circumferentials in American hip is less than six hours of segmental, and greater than six from TAL to TAL would be considered circumferential. And how patients had superior outcomes compared to segmental resections, and that's pretty well borne out in the literature now that in an irreparable labra, it's better to give something back than to take away. Because if you do an adequate femoroplasty and pincer resection and capsule rework, but you've taken away the labrum that's degenerative and torn, the patient work. Pairing now reconstructions to repairs, how about in the primary setting? So you didn't plan on going in to do a reconstruction, but you got there and there was nothing to repair. So how do those patients do it? And we've seen this now at two years, that circumferential reconstructions for irreparable labra in the primary setting with minimum two-year follow-up, and we pair match this to a nested repair group, and of 37 patients, pair match to 111 control patients, the functional outcomes were similar to the benchmark groups. So I can tell you that a lot of them honestly was a peritrocanteric work that was the indication. They came in with a lot of partial or full thickness gluteus medius tears, and we're treating them similar to the shoulder. So if I do a rotator cuff repair in the shoulder, I'm going to go inside the shoulder joint and assess what's going on in the joint. Look at the labrum, look at the biceps, look at the cartilage. So we see the hip no different. If we're there for an arthroscopic procedure, why not give the hip an opportunity if the chondral surface appears well enough for repairability of the joint. And then we'll move on to the peritroke compartment and take care of that indication. It is a cutoff. We don't do it in reconstruction groups. They've had a higher failure rate in the repair groups. Not really generalizable to the population from the literature that's been out there, but I think that the point is that if you have a hip that otherwise has appropriate appearing articular cartilage and you've diagnosed it, but be prepared. So we've also put out a predictor's article on the need for primary label reconstruction during hip arthroscopy. And it's a predictive model using 1,400 patients. And specifically looking at things like tonus grade, LCEA, alpha angle, age, and BMI. And it's truly a formula that you can put in and you can get your predictive value. But the goal is you should have this conversation with your patients. Maybe not to that granularity, but knowing that they're a high likelihood of this particular procedure. So you can counsel them on the recovery protocol. So for us, it's two weeks on crutches versus six weeks if you're in reconstruction because we need more time for that graft to heal in. So if you're in this case and you see this kind of labrum, you know, it can be repaired or maybe not. And you're kind of going toward the reconstruction aspect of it is probably the most important factor. Allografts, TFL, SEMIT, ITB, anterior posterior tib, dermal grafts, obviously autografts are available to you at any point in time. But the point is, get facile with this, get in the lab and test things out so you understand how the graft is going to feel in your hands and how it works inside the joint. We've done a consensus study on this and we simply asked surgeons, you know, what do you use? What would you do? And it seems like allograft was the predominant choice, segmental reconstructions. You don't have your staff kind of chasing grafts from freezers and calling reps and, you know, have some for every case. So this particular management, the graft is being brought in from the mid-anterior to the posterior lateral portal and then we anchor from the front to the back. So it's critical that your staff and your assistants have a working knowledge of your workflow and they can contain the sutures in place so you don't get tangled up. So a couple of cases to kind of highlight what we would do here. So 19-year-old female, recurrent hip pain for two years, so which is consisting of a labral repair and a capsular placation. So here is her imaging. Again, it's the right hip. Considerably, possibly you could say that she had a little bit of an oversection there. So here we are intraoperatively. So, you know, she had a labral repair. Labrum was repairable at that time. And so now we're looking at it. And I can see sutures in place, but the issue now, in my opinion, is that it just wasn't enough labrum to begin with. Oh, I lost it, we're back. So bottom line, it wasn't enough. So the probe is falling into the labrum here. And I think that's the issue, is that labrum was diminutive to begin with. So for this particular case, could you do an augmentation? Sure, but in my hands I'm going to take out the old because the tissue quality is very poor and I'm going to give her a new. And it's going to be from where she needs it. So the anastomosis should be from the front to the back, depending upon where the hip has good tissue. And the goal is to reconstitute that seal there. So when you let traction off the hip, you can see that you have given her more stability. And they feel better almost immediately. They have this sort of sense of stabilization at their post-op day one appointment with PT. Similar case, 22-year-old female, right hip anabursion of 40 degrees and BMI of 21. So here is her x-rays from an repaired well, complaint of pain. And we did a diagnostic interarticular injection, which lo and behold, gave her relief. So we were there for the right reasons. And this is what we found. When we got on the hip, you look at where the labral suture is at. And again, that's where I would have gone. It's asking for more tissue. And so you give it to her. And again, these patients do remarkably well because they have that stability from the reconstitution of that seal with the head kind of falling in and under. Sixty-three-year-old crossfitter. So here we are, advanced age, okay. So left hip pain for seven years. Had a prior scope in 18. So already it was indicated and continued with pain. So the red arrow simply shows that potentially some under-resection in certain areas, even in the false profile you can see. This is going back to Dr. Saffron's talk about adhesions. I mean, you can see, I'm going to highlight, you can see the capsule in the labrum there. But then as we come up, it's just adhered. It's all one. Severe scar formation. And so what are the options here? We simply have a choice. This one for us is sort of, while we're there, because of the advanced age, I want to give this tissue a fair shot at durability. And again, I don't think you're wrong for taking down the scar only. We've done that in the past. But right now with the CAM, the residual CAM, both in a circumferential fashion on Dunn and the false profile. So last case is actually a primary case. I highlight this because you will see these patients in your clinic. They will come to you. So anyone in the room saying total hip at this point? She's 27, okay? So is it fair? Putting that word apparent there is pretty critical because this is a calcified labrum. It's interesting. Your MRI report in this patient will say no labral tear because there is no labrum left. So the radiologist may miss it and say, I just see bone. I don't see anything that's of soft tissue in that area, therefore there's no labral tear that exists. So be very kind of analytical when you look at these MRI reports if they're coming from an outside facility. I actually had to get a reread on this because I don't think they had all the data to provide us with a report that was needed. But in this case, you've got to know that getting into this somewhat different techniques, we call this the inside-outside hip, the labrum while you make your access. But this is a complete takedown of bone. There's no labrum that could be repaired. So you have to get after this pretty aggressively and move swiftly through the case so that you can perform your reconstruction and you're keeping your traction time down. We prefer no more than 60 minutes for any case. So we'll do this work. Then we'll move on to the femorplasty and come back for our graft. But again, on-the-fly label reconstructions for the primary setting, I mean, have a graft board prep available for each case. Have grafts on standby. You know, some good music doesn't hurt. But lots of suture anchors. And for this, with the pull-through, this is very reproducible for us with pretty good ease as you're working from front to back. And you can tension this as needed. But the goal is to make it reproducible for your team so that everyone in the room knows the steps and it becomes a fun case. The work is really the prep from the bony preparation that's needed to be done before you get in there with anchors. So just to sum it up, there's no peak or biologic department work. And now, when you're unleashing sort of the anchors progressively, you're working more in a peripheral compartment where you're just passing and pulling and tying. So I'm not advocating for any particular, you know, anchor number 1 through 14, whatever it is. So from a surgeon and a team perspective, it's very reproducible. We're looking at this in the lab now, looking to see if we can reproduce some of Dr. Philippon's work and others for checking the seal and the suction seal of the hip. This is, again, from a TAL. The TAL will push me up shortly. So to summarize, again, be prepared because you will need to perform this if you're kind of venturing out in hip arthroscopy. You need to have this workflow, but be prepared for it and practice, practice, practice, practice.

labral deficiency

hip arthroscopy

labral reconstruction

tissue quality

allografts