Okay. So I think when approaching the labrum I always think about how do I restore the anatomy as best as possible. And I think about it from a macro and micro anatomy perspective. And how can I best restore the structure and therefore the function. So an anatomic labral repair, whether repair or reconstruction, we want to maintain the suction seal. We want to provide enhanced stability. We want to dissipate contact pressure. And we also want to address pain and proprioceptive fibers as well. And there's a couple things that I keep in mind when I approach a labral deficiency, whether it's repair or reconstruction, is I want to place my anchors as close to the subchondral bone as possible. I want to use small anchors. I want to have minimally traumatic devices. And then I want to just provide a repair that is on the face of the S-tabular rim rather than everting it. As far as decision-making goes, oftentimes when you look inside the labrum, especially in a revision situation, I think you'll get a bigger picture as far as what's going on and what needs to be done. So I do think that diagnostic arthroscopy is really important. And in some cases, like in this one, the labral tissue actually looks fairly sufficient. But in terms of your treatment options, basically we have four things that we can consider. One is repair, reconstruction, augmentation or debridement. And I think depending on the appearance of the labrum, I think at that point you'll make a decision as far as what to do. In my own personal algorithm, I think it's fairly straightforward. If you see a labrum like you do on the left, you've got substantive labral tissue, it looks pretty healthy. These are the ones that are amenable to repair primarily. If you see labral tissue like you see on the right, these are ones that the labral tissue doesn't look so healthy. And in this case, you may consider either selective labral debridement, augmentation or reconstruction. And I would say that there's a role for all of them. You can't just approach it and just do the same thing every time. But there certainly are cases where I feel like the labral tissue is substantive and I'll just debride it. Sometimes the labral repair may have captured the labrum too much and averted it. And sometimes when you release some of the stitches you might get some of that seal back. In other cases if you do have a decent amount of tissue that's remaining that goes between the articular cartilage and labrum, sometimes you just have to augment it. In other situations you have no labral tissue remaining at all. In that case obviously reconstruction I think is a good option. In my personal practice I probably end up doing reconstructions about 20-30% of revision cases. I would say in primary cases less than 1%, so pretty infrequent. I think the principles are fairly consistent whether you're doing reconstruction or augmentation. First you want to identify the labral tear. So if you look at a hip like this and you see this tissue, you know that this tissue is not going to be very good. There's a radial split. There's fairly deficient tissue, especially on the capsular side. Next you want to then do your rim prep. In addition to that any remaining pincer you'll address. And then when you want to measure the extent of the labral pathology, I'll go ahead and place one anchor, in this case medially. And then use like either a device or sometimes I'll just use a knot pusher and go all the way laterally and try to measure the size of the labral defect. As far as a labral graft prep, it can consist of autograft, allograft, semi-tendinosis, tibialis anterior, fascial grafts. I think the principles are relatively the same. You want to tubularize it. I like to shoot around 6mm in terms of width if I'm going to reconstruct it, and maybe about 4.5-5 if I'm going to augment it. And then lastly, graft placement. You can either shuttle it in with an anchor on just one end, or you can fixate it on both ends and then put your intervening stitches in between. And for me it depends on the size of the labral defect. The larger ones it's hard to fixate both sides, so I'll just fixate one and then sequentially reconstruct as I go along. But if it's a segmental one, then I'll put stitches on both the medial and lateral extent and shuttle it in that way. So what is the biomechanical evidence of labral reconstructions? So labral biomechanics are good. Obviously repairs are also very good, but reconstructions are a good possibility as well. And I think what we see is that labral reconstructions do improve the biomechanics. Mark's group and other groups have shown that this clearly is better than a labral tear or labral resection, but not as good as primary repair. And the outcome studies looking at segmental labral reconstructions are also very good. Patients do well post-labral reconstructions with a high return to sport as well as increased patient report outcomes. When you look at the biomechanical properties you can see that we've done some contact pressure studies looking at intactive versus labral repair and labral reconstructions. And these are the same specimens. So the first test was done with an intactive, then we just did a primary repair in the anterior superior quadrant. Then we removed the labrum and did a total labral reconstruction with a fascial autograph with typically about 10 anchors around the entire acetabulum. And we used tech scan pressure testing to understand the contact pressure. And when you look at these heat maps you can see that there is a difference in the appearance when you compare intact to labral repair and labral construction. And what we see is that when you look at contact area we do see a significant difference between an intact hip, a labral repair and a labral reconstruction with the labral reconstruction having the lowest contact area. And when you look at the suction seal for an intact hip, you do maintain the suction seal. With a labral repair you actually maintain it. We don't have volume but you can imagine there's a pop there. And with a total labral reconstruction you kind of lose that suction seal. For some reason once you perform this extensive reconstruction the seal has been violated and hard to reproduce. So what about labral augmentation? So we've done similar biomechanical testing on augmentation as well. And similar setup. We started with an intact hip, then we did a rim prep followed by a labral augmentation and finally a labral reconstruction. And similar testing we did that suction seal analysis with a low displacement curve. And with an intact hip you can see that's that wider broad base solid line. That's what it looks like when you do this type of analysis. The rim prep is also similar but when you do a reconstruction augmentation it does affect that suction seal or that low displacement in those settings. And there's no significant difference between the two groups. Bruno Capuro has done some interesting labral reconstruction studies using this polyurethane scaffold. And again very similar when you compare it to intact then labrectomy and then this polyurethane scaffold you do find that there's increased contact area but decreased contact pressure and peak force with these different craft options. So in some cases you do have to consider like more of an extensive labral reconstruction. This is a case of a primary labral reconstruction for heterotopic, I'm sorry, for labral ossification. And these are kind of interesting cases. You can see on the left like this large area of labral ossification. And then after like extensive resection you can get that acetabular rim to look somewhat anatomic. I would say that they're obviously pretty challenging cases. And when you do your acetabular rim trimming you do want to do it both under fluoro and direct visualization. You know have a healthy capsulotomy because you're going to have to really extend much more posterior and lateral than you're used to. And this is really going from like 2 o'clock to like 10 o'clock. And once you do your complete acetabular rim resection you can see that there really is no labral tissue left. And I think you can make an argument to reconstruct it. Some people might argue that you could just leave it alone and once you remove the pincer the patients will do fine. But in this particular case we elected to do a reconstruction. So again this is at 10 o'clock to 2 o'clock or 2 o'clock to 10 o'clock. I place an anchor as far lateral, posterolateral and then use a device to go as far medial as you can. And you want to place that other either grasp or like at the apex of the rim so that you get a true measurement of the acetabular rim itself rather than going kind of horizontal across it. And then in these cases I'll go ahead and place the anchors first. I think one of the things that I think I've learned is that you want to really place that anchor as close to the labrum, that subchondral plate as possible. And so in this particular case I think we had like eight anchors kind of all the way around the entire acetabulum. So once you place all your anchors, my assistant will be doing the graft prep. We'll take the traction down. We'll go into the peripheral compartment. And while the graft is being prepared we'll address any peripheral compartment work. Once that is completed then we'll put the hip back on distraction and then we'll go ahead and do our shuttle of the graft. So because of the extensive size of this labrary construction it's hard to place and fixate both the medial and lateral extent. So we'll go ahead and fixate the medial extent. I'll shuttle it through the DALA portal, distal accessory antelope portal. And I'll do most of my work through that modified anterior portal. So here we've got that medial extent has been fixed into place. And at this point then we'll go ahead and sequentially place our anchors or we'll tie our anchors from medial to lateral. I think one of the things that I think is important with these larger grafts is that you need to be able to pull traction so that you can sort of extend the graft as much as possible so it doesn't bunch up on you. And so you need to be able to pass your stitches and then have another instrument to kind of pull gently on the labrum so that it's not redundant. And so you want to get as much excursion of the labrum as possible because otherwise you'll have a short graft or the graft will be somewhat loose and redundant. So this is after the complete total labrary construction. We'll take the traction off. We'll assess our suction seal. And you can see that we really try to place that graft on the face of the acetabulum itself so it doesn't evert the labral graft and it's not placed proximal or too high above it. And then we'll do our dynamic assessment to make sure that we've got impingement free motion, we've restored the suction seal, and replaced the labrum as best as we can. So this is an interesting study that Molinado and Bamfy put together looking at the biomechanics of total labor reconstructions. And in this particular study they wanted to see like if you make the graft bigger can we restore that suction seal? And so when you look to the graft, the blue represents an intact hip, the red represents a deficient labrum. So when you do like a labrectomy, for example, and then they did a circumferential labor reconstruction but less than six and a half millimeters. And you can see that that doesn't restore that suction seal. But when they went to that bigger, greater than 6.5 millimeters, they're able to restore the suction seal. So while they're able to prove that biomechanically with a larger graft they're able to do so, this was done in a cadaveric model. And using a six and a half millimeter graft is challenging in and of itself. And so when you use one that is greater than six and a half millimeters, and in this, at least the example that they show, I mean, it almost looks like it's double the size, I think would be pretty challenging. I don't know if it's been done in patients, but I guess something to keep in mind if you're preparing grafts. Bendome's group looked at circumferential labor reconstruction in reparable labral tears in the primary settings and found that when they compared reconstruction to repair a match group, they found that the repair group did better across all patient report outcomes. And Dome's group also looked at labor reconstruction in irreparable labral tears in athletes for revision cases and also found that when returning to sport the repair group did better but not statistically significant. But the repair group also had a higher rate of revision and conversion total hip replacement but also not statistically significant. The MASH group looked at the outcomes after revision hip arthroscopy comparing repair versus reconstruction and again finding that there was no significant difference in patient report outcomes when comparing repair and reconstruction in a revision setting. So a couple pearls that I would think about, you know, in terms of like going over the literature, both clinical studies and biomechanical studies, is that when you're doing a labor reconstruction or any time the labrum is not present, obviously it's affecting that chondrolabral junction. And I think the larger the reconstruction, the larger area that the labrum is irreparable or deficient, unfortunately I think that chondrolabral junction is violated. And I think that probably affects the suction seal the most, at least at time zero. The other thing that you want to keep in mind is that whether you're doing a total labor reconstruction or a segmental labor reconstruction, that anastomosis between the host and the graft is something to keep in mind in order to restore the hoop stresses around the entire acetabular rim. And I would say that you probably want to avoid a non-anatomic labor reconstruction at this point. So in summary I would say that labral anatomy restoration is critical. I like to preserve as much native tissue as I can. So in most cases I'll bias myself towards an augmentation because I want to maintain as much of that chondrolabral tissue as I can and augment if I feel like the collagen is deficient. Labor reconstruction, you want to consider size with graft type. I think the principles are mostly the same, whether you're using allograft or autograft or different tissue types I think is probably just up to surgeon's discretion. And in general you want to recapitulate the normal anatomy as best as possible, whether repair, reconstruction, or augmentation. And the long-term clinical outcomes are still needing to be studied at this point. I think we've got some good information biomechanically and short-term data, but I think the long-term data obviously will be able to yield how successful labor reconstructions are in primary and revision settings. Thank you.

labral repair

hip joint

anatomy restoration

function restoration

suction seal maintenance