So, my assignment this morning, thanks for inviting me Ivan and AOSSM, great faculty, I'm honored to be with you guys. So how many of you in the audience have performed one or more labral reconstruction? What about a labral augmentation? And what about a circumferential reconstruction for, okay, okay, all right, well, these are my disclosures. So we started doing this back in 2005 and those of you, I see some of our old fellows in here, Penny and I were in the operating room and we had this soccer player who had surgery in England actually by a very good surgeon. He was a professional soccer player and the only thing missing in this patient was a segment of his labrum. So, and I had done capsular segmental augmentation, tendon, rectus tendon augmentation of a small segment but I had never done a larger segment. This was about, I remember, maybe five centimeters. But it was a significant deficiency, there was no seal, great osteoplasty, everything else was perfect. So we went ahead and did it. And this gentleman, I remember, was retired from his premiership soccer role and he went back and played for 10 more years. So that was encouraging. After having done him, he sent a couple of his friends and that's how we got started doing the labral reconstruction. But the truth, the indication was irreparable complex tear with minimal tissue. Sometimes you have the ossified labrum. And again, back then, I didn't really realize the importance of the circumferential fibers. And now we've evolved preserving this circumferential fibers. But at the time, now, we were doing segmental reconstruction and I still do those for the proper indication. And our goal is not only to put the graph there but you want to make sure it's functional. So we want to make sure that we recreate the seal. And truly, the labrum is a triangular fibrocartilage structure and it really act as a seal. And as Shane showed, not only the capsule is important for stability, but we believe that the labrum is important. You want to have, recently we've published on the segment, the labral height. And we feel at minimum this six millimeter is important to preserve the seal. So this is what I was referring to. So those who had less than six mm of height didn't have as good of a seal. So if I go in, I see a deficient labrum, I measure it. And again, if it's less than six, I'll do my best to augment it. Or if it's truly deficient with no base, circumferential fibers, we'll do a formal reconstruction. So the early work, we found that, this is actually, again, if you watch that video, this is without the labrum after work, I don't know if we can have the sound on this. That's okay. You can hear the pop. But without the segment, there's no seal. With the segment, there's a seal. What we found is like in other procedure we do in hip arthroscopy, if the joint space is less than two millimeter at the sore seal, our results were inferior. But upon biomechanical analysis, we did a lot of work with Dr. Kneppel, we found that truly an intact labrum will trap the synovial fluid in the interarticular space, will improve the destructive stability, and partially restore time-zero acetabular contact area stress. So these are reference for using the technique of labral recon. I can refer you to those for video and techniques. I won't go in details with those, but I'll share with you some of our pearls, both for recon and for augmentation. So number one, for us, if it's a young patient, what I mean by that, a young active patient less than 40, most of the time I will use autologous IT band. And I know there's been a lot of talk about, okay, is there donor morbidity? Is there any issues with harvesting the IT band? In our hands, if it's done properly, and you close the window properly, we use absorbable sutures number two and number one, we haven't had any issues with that. But you got to make sure if the IT band is too tight, you got to release it and leave it open. And when you harvest, we measure the segmental defect and usually, or the augment defect, we want to be 20, 30% longer. So this way you have room, if your measurements are not exactly the way it should be, I always harvest a little longer. And again, I'll just go back to the preparation, make sure, so I start doing this myself, but now we have good assistants doing it for us, so we save time doing the procedure. It's a little longer, if you're in a surgery center, doing the autologous part might be more extend your time of the operation. But for us, we have good team and we tubalize the graph, we use vicral suture, and initially when I started doing this, I used to put a loop on the lateral portion of my graph. Now with the new instrumentation, we don't have to do this, and it's easier to place the graph. So inserting the graph, sometimes it can be challenging if you have a large graph. So you can pass it through the cannula. Now what we've done, I always pass, a pearl I can tell you is when you pass your graph, I recommend to pass it through your lateral portal. The soft tissue envelope laterally is less thick, and usually, depending on where you place your portal, you go in the intermuscular plane, and it's relatively easy to pass your graph, even without a cannula. So that's what we do now, we use a slot cannula, or even without a slot cannula, I place the anchor, most medial anchor, and just slide it through the suture. Now what you're seeing inferiorly here is the augment, I'm placing the graph behind the residual circular fibers. After having placed my first anchor, I'll just make sure it sits properly, and then the rest is relatively easy. This is the most lateral portion, the anchor has been placed, and then watch, this is the instrument I use now. I used to have our fellow hold the graph, and then pass the suture through. Now with this instrumentation, it's a single pass, and it's super easy to do actually. It saves a lot of time for us, and makes our manipulation of the graph and the joint much easier. So this is a right hip looking from the top, and again, when I do a right hip, it looks upside down. It's just for instrument crowding, it's not a pearl I can tell you. When you do a right hip, make sure that, for us, we like to have it upside down so your instruments diverge instead of converging. So securing the graph a little bit for us, we use the same rule. We'll try to place an anchor about a centimeter apart, and we'll loop or pierce depending on where we want the graph position. So if you want a graph more on the face of the acetabulum, we'll pierce it. If we want to evert it, and in the hip, as we know, it's a weight bearing joint, so sometime eversion is necessary because when the compression is going to place your labrum more on the face, we'll loop it. So this is a loop version. You're looking at the base of the subspinal region, we compress it, and you want to make sure it's well opposed. And I use FHs 5 to 7 depending on the position. So these are guidelines for how we select our anchors. We immediately, I like to use a null suture anchor, especially at 3 o'clock position, for many reasons. I've revised a few patients where, unfortunately, the anchor was pierced, perforated the wall, and then the tip of the, especially non-absorbent anchor, the tip was irritating the psoas. So those are sometimes difficult to remove when you do a revision, and it causes sometimes inflammation of the psoas. So immediately, we use a null suture anchor. At 12 o'clock, I usually use a 2-3-2-9 biocomposite anchor, and posteriorly, at 9 o'clock or 10 o'clock, I'll use also a null suture anchor, the curvilinear delivery system, and that really makes it easy and safe as well. Now don't forget to close the capsule, and we've done a lot of work on this. And as Shane mentioned, the capsule is becoming more of an element of, I mean, we all pretty much agree that we need the capsule, and closing it, doing your capsulotomy is important. You can use a parallel capsulotomy or a T-capsulotomy, but make sure that you close it at the end and try to prevent violating the lymphoma ligament. Recently, and I would say over the past couple of years, I've seen a lot of patients refer to us for huge capsular defect, especially in the psoas mass area, and those are challenging, and that's why Shane just alluded to that and discussed that. We do graft now for these large defect. So when we're done with our augmentation reconstruction, we always close the capsule. And in revision cases, often, recently, as I said, we have to perform a capsular recon as well. So this is our outcome. We publish our 10-year result in JBGS on primary labral repair debridement. Patient satisfaction mean at 10 years was 10 out of 10. It's interesting, in the recon, there's been some debate, as I said, about circumferential versus segmental. These were segmental labral recon. Most of them, we just remove what's deficient. Our patient satisfaction at 10 years was 10 out of 10. This was also published in JBGS. So we had 91 hips and seven required revision hips, and most of them was because of adhesion. I remember early on, we were getting a lot of adhesions. What we decided to do right after 205, we started to do circumduction right after surgery. It's a very big part of our rehab protocol. Circumduction twice a day, clockwise and counterclockwise. And our shoulder colleague actually had a discussion with them, and that's how we came up with that circumduction rule and the flexion extension, obviously. And then what we found is that recently, and I don't want to diverge here, but recently we've been using a TGF1 blocker based on the work of John Yeward at Pittsburgh at UPMC. We're doing some work now. We have an NIH grant and Department of Defense grant where we're going to look at Losartan effect on fibrocarilage, but also on adhesions. Basically, since we started using Losartan low dose off-label, we found that patient developed less adhesion. So again, that's work in progress. We're doing a clinical trial on that, but these adhesion problems are pretty much resolved. So we had 21 hips converted to a total hip. Those who were less than 45 at the longer survival rate versus over 45. So age appeared to be a factor in that situation. And again, if you look at survivorship curve, the joint space is a significant part of the outcome. So we look also at our learning curve. So we look at the results of our first 100 patients with autograft IT band, and our most recent at the time of this paper. And we found that our selection criteria were good, but not optimal. So now what we do is we look primarily, of course, we look at age as a factor, 45, and joint space narrowing. We're way more selective than we used to be with joint space narrowing. So for us, 2 million or less, and any three points of the source cell, we will not proceed with the intervention most of the time. So what are the pros of Recon? You're going to recreate the seal if it's done the right way. We have proven good clinical outcome up to 10 years now, and even longer. It's not published, but in peer-reviewed literature now, we have 10-year outcome. The cons is you might have a potential with autograft, donor site morbidity. You can have difficulty technically, but most of the surgeons now who have experience with arthroscopy can do this procedure relatively simply. So the take-home point, I think you have to make sure you select your patient properly. You got to decide, do you want to do a segmental reconstruction and augmentation? It's the same technique basically, except with the augmentation, you put it behind your circumferential fibers. Make sure you get the right graft size. And the rehabilitation, as I said, you want to prevent adhesion. So rehab is important, and eventually when I have more data on our clinical trials, I'll share with you, hopefully we're going to show the effect. But right now I can tell you, based on our preliminary analysis, it definitely has an impact on minimizing the adhesion with the Lusartan. And try to preserve, I really believe preserving, this is two-edged sword, preserving the fibers, you might, some people will tell you that you'll have still some pain from the nerves, but the reality, there's also no short receptors, and also the circular fibers of the labrum went on the weight bearing, these circular fibers that ring contain the two columns, the anterior and posterior column of the acetabulum. And there's a paper by Gruen showing that on the weight bearing, there's expansion of your column. So preserving the circular fiber, I think is important in the labrum. Thank you.

labral reconstruction

hip arthroscopy

irreparable tears

triangular fibrocartilage

graft sizing