Hip Labral Reconstruction: Techniques and Outcomes

Abstract

Purpose of Review

With increased understanding of the biomechanical function of the acetabular labrum, more attention has been directed towards surgical techniques that preserve or restore normal joint anatomy. While labral repair has been shown to produce superior outcomes to labral debridement, repair is not always possible in the setting of severe labral intrasubstance tearing or deficiency. These patients were previously left without suitable arthroscopic treatment options.

Recent Findings

Labral reconstruction is an emerging procedure that has been shown to offer promising outcomes for traditionally difficult-to-treat hip pathology. Short- and mid-term follow-up studies have consistently demonstrated significant improvement in patient-reported outcomes, function, and patient satisfaction postoperatively, often despite less favorable preoperative characteristics.

Summary

Labral reconstruction is a viable arthroscopic treatment option that has been shown to reliably produce clinically meaningful results in patients with severe labral pathology that is not amenable to repair/refixation or augmentation.

Introduction

With an increasing number of orthopaedic surgeons performing arthroscopic procedures on the hip, techniques for managing labral pathology continue to evolve. Historically, arthroscopic treatment options for labral tears have included debridement and repair/refixation (for the purposes of this manuscript, we will use these terms interchangeably as the distinction is unclear). However, with improved understanding of the biomechanical function of the hip labrum, more focus has been directed towards techniques that restore natural joint anatomy [1••, 2••, 3–6]. While refixation allows for restoration of the labrum’s suction seal [7–10], it is not always possible to repair severely damaged tissue or segmental defects. As a result, these patients were previously left without suitable arthroscopic treatment options.

In recent years, however, arthroscopic hip labral reconstruction has become an increasingly utilized technique for treating the previously irreparable labrum. Segmental labral reconstruction was first described in 2010 by Philippon et al. [11••]. More recently, complete labral reconstruction techniques have been developed to account for patients with global acetabular overcoverage, as well as extensive labral ossification or damage. Complete labral reconstruction also minimizes inherently weak junction points between the graft and native labrum and decreases the chances of leaving acetabular and labral pathology unaddressed or undertreated. Multiple studies have demonstrated favorable outcomes among both primary and revision reconstruction patients, often despite less favorable patient charateristics [12–18]. In our practice, labral reconstruction is used as a primary procedure for select patients and is the mainstay of treatment in the setting of revision hip arthroscopy where previous labral treatment has failed. In this review, we will discuss indications and contraindications for labral reconstruction, the senior author’s preferred surgical technique, and an overview of reported outcomes data following labral reconstruction.

Pathophysiology

The acetabular labrum is a fibrocartilaginous structure that surrounds the osseous acetabulum and plays an important role in maintaining the normal mechanics and overall physiologic function of most hip joints [19•]. The labrum has been shown to distribute loads and contact pressure within the acetabulum, increase coverage of the femoral head, and form a suction seal that ensures adequate joint lubrication. When this suction seal is disrupted, such as by a labral tear, the biomechanical environment of the hip is altered. Over time, this is believed to have detrimental effects on the articular cartilage and may lead to osteoarthritis [1••, 2]. Furthermore, labral tissue exhibits a high level of free nerve ending expression and damaged tissue may act as a significant source of pain [20••].

Tears of the acetabular labrum are frequently associated with underlying structural abnormalities, such as femoro-acetabular impingement (FAI) or dysplasia [21, 22]. FAI may result from excessive coverage of the femoral head by the anterior superior acetabular rim (“pincer-type” impingement), abnormal femoral head-neck offset (“cam-type” impingement), retroversion of the acetabulum, or a mixture of these deformities. FAI results in the compression of the labrum between the acetabulum and anterior femoral neck, damaging the tissue over time [23]. Labral tears exist on a continuum, ranging from mild peripheral fraying to complex intrasubstance tears and segmental defects. While numerous studies have demonstrated superior results with restoration of normal labral anatomy via repair when compared with debridement [7–10,24••], severe tears are often not amenable to repair.

Indications

Labral reconstruction should be considered for patients with symptomatic labral pathology that is not amenable to repair (Table 1). Prompt surgical treatment has been shown to lead to better hip functionality and decreased risk of revision procedures when compared to conservative and delayed operative management [25, 26]. However, a trial of conservative management is often wise depending on the duration or severity of symptoms and other factors such as urgency of need for return to sport, work, or activities of daily living. Non-operative management may include activity modification, non-steroidal anti-inflammatory drugs, physical therapy, and intra-articular corticosteroid injections. When symptoms are sufficiently limiting for a meaningful period of time and non-operative interventions have failed or are likely to fail, surgical intervention should be considered. Candidacy for hip arthroscopy is further evaluated with imaging. In our practice, anterior-posterior pelvis, 45° modified Dunn lateral and false-profile radiographs, and 3-T magnetic resonance imaging are reviewed. CT scans are used selectively for complex bony pathology. Diagnostic injections are performed liberally when there is a question as to the source of symptoms. Relative contraindications to hip arthroscopy include significant osteoarthritis (> Tönnis grade 1) or dysplasia (lateral center edge angle < 20°, Tonnis angle >10°). Patients with asymptomatic labral pathology are not indicated for prophylactic hip arthroscopy [27, 28].

Table 1.

Indications for reconstruction vs repair

Reconstruct	Repair	Favor reconstruction	Favor repair or debridement
Revision procedures	< 25 yrs Mild intrasubstance labral tearing	> 35 yrs with moderate intrasubstance tearing	Short duration of symptoms Coexistent pathology that is likely primary pain generator such as more extensive arthritis than anticipated from preoperative imaging or tumor-like conditions (e.g., synovial chondromatosis, pigmented villonodular synovitis)
Severe labral damage		Older female
Deficient or ossified labrum		Severe synovitis
Collagen disorders		Long duration of symptoms
Severe pincer-type impingement		Mild chondrosis.

The decision to perform labral repair versus reconstruction is determined intraoperatively. Tear severity is assessed based on the guidelines established by the Multicenter Arthroscopic Study of the Hip (MASH) Study Group [29]. Mild tears are those with some degree of fraying but stable rim configuration. Moderate tears include those with an unstable rim and intrasubstance damage less than 50% of the substance at the site of the tear. Labral tears with rim stability and intrasubstance damage that is more severe than fraying but still less than 50% of the substance at the site are also classified as moderate. Severe tears are those with complex tearing involving more than 50% of the substance at the site. Hips with mild intrasubstance tearing are generally repaired. Reconstruction is performed for labral tears with severe intrasubstance damage, ossification, or segmental defects (Fig. 1). In cases of moderate damage, reconstruction is often preferred for patients 40 years of age and older. In our practice, complete labral reconstruction is generally preferred over segmental reconstruction Table 2.

Fig. 1.

a CT scan of 42-year-old woman with ankylosing spondylitis resulting in pincer-type FAI from severe labral ossification. b 45-degree modified Dunn lateral radiograph of left hip demonstrating cam- and pincer-type FAI. c 5-year follow-up radiograph (age 47) after bony resection, cam osteoplasty, and complete labral reconstruction

Table 2.

Pearls for an effective and reproducible complete labral reconstruction

1. A larger portion of the labrum may have damaged, pain-generating tissue than is first apparent. 2. Resecting the entirety of the labrum permits for easy access to correct acetabular rim abnormalities without incurring labral-bone mismatch issues, as are likely to arise when large acetabular resection is required (i.e., coxa profunda). 3. Native labrum-graft junctions are inherently weak and therefore are eliminated or positioned far postero-inferior in areas of low stress. 4. The psoas should never be visualized through the central compartment. This means limiting your capsular incision to well above the 3 o’clock position (for a right hip). 5. Care should be taken to position all anchors as close to the articular surface as possible without penetrating it, to ensure that adequate suction seal is restored by the graft. 6. Graft length measurement is inherently imprecise. This technique accounts for that and can be used to avoid length mismatches in segmental labral reconstructions as well. 7. Use an atraumatic grasper through the DALA portal to place the graft at the appropriate position and tension on the rim. Your assistant should hold the graft in this position while the sutures are tied. The graft should be grasped and manipulated afew times as possible to avoid fraying. 8. Trimming the graft is undesirable as it compromises the reinforcing sutures running through the graft. 9. Grafts must not be too short as this leaves a gap that may weaken the labral suction seal. 10. It is important for the surgeon to drill his or her own anchors while the assistant holds the camera and visualizes the articular surface. 11. The hip should not be pushed beyond its comfort zone for the entirety of the recovery and rehabilitation process regardless of external time pressures.

The type of impingement present may also influence whether repair or reconstruction is performed. Pincer-type FAI either can be focal, typically in the anterosuperior acetabulum, or may be global as is seen in coxa profunda and acetabuli protrusio. While there are certainly cases with focal anterosuperior over coverage in which the labrum can be repaired following correction of the acetabular deformity, there are other times where the labrum is hypoplastic or damaged through crushing forces which render it beyond repair. In these cases, a segmental reconstruction may be sufficient. However, there are cases where the extent of the pathology may be underappreciated. There are also technical considerations with respect to native labrum-graft interfaces and graft-defect length mismatches, which argue for a complete labral reconstruction. In patients with more global pincer lesions, the over coverage is often a result of, or exacerbated by, labral ossification, particularly superiorly and posteriorly. To adequately address these bony lesions, the labrum usually must be more globally resected. A properly performed complete labral reconstruction will reliably restore the suction seal in these cases.

Cam-type FAI inflicts more of a shearing force at the chondro-labral junction. In cases of more severe cam-type FAI, there is often delamination of the acetabular cartilage with damage at the labral base. This may be accompanied by unfused os acetabuli and/or acetabular rim fractures. In these cases, the bony fragments are often intercalated within the labrum. Upon removing these, the labrum is often damaged beyond repair and a labral reconstruction is indicated. Similarly, in severe cam deformities, particularly those with relative femoral retrotorsion, the extent of the damage extends over a wide portion of the chondral-labral junction. The intrasubstance labral damage in these cases may be variable and a labral repair is often sufficient. If the damage is predominately focused on the acetabular cartilage with a delaminating lesion with minimal chondro-labral separation, this may contraindicate a labral reconstruction, and refixation of the chondral-labral unit as a whole may be preferable.

Regarding graft selection, multiple options for reconstruction have been proposed [13•, 14,30,31]. Early techniques tended to favor the use of autografts. More recently there has been a shift towards allografts [32,33•]. Rahl et al. found no clinically significant difference in outcomes based on graft type alone, with both allograft and autograft leading to significant improvements in postoperative patient-reported outcomes [34]. In a small series comparing hamstring autografts and allografts, Maldonado et al. observed no difference in outcomes among patients who underwent primary reconstruction based on graft type [35]. A survey of high-volume hip arthroscopists reported that 91.7% of the surgeons surveyed preferred an allograft over an autograft alternative [33•]. In our practice, frozen tensor fasia lata allografts (Allosource; Centennial, CO, USA) are preferred for their consistency of size and length, decreased risk of donor site morbidity, and ease of tubularization.

Author’s Preferred Technique for Labral Reconstruction

Upon entering the operating room, patients are positioned supine on the operative table. In our practice, a post-less distraction table attachment is used (Pivot Guardian; Stryker Sports Medicine Sunnyvale, CA, USA). Patients are placed in 0–15° of Trendelenburg and the hip is distracted 8–10 mm.

Three portals are typically used for this procedure: anterolateral (AL), mid-anterior (MA), and distal anterolateral (DALA) portals. A fourth posterolateral portal is occasionally required. The patient’s native labrum is resected from the transverse acetabular ligament (TAL) antero-inferiorly to the 8 o’clock position posterior-inferiorly through the AL and MA portals. We have found that the anatomy at the junction of the antero-inferior labrum and the TAL varies widely. We believe it is important to maintain the integrity and stability of the TAL. At times, this will be repaired or stabilized with a suture which also passes through the graft (Fig. 2). At other times, labrum is not resected in this area if it will destabilize the TAL. In this situation, the antero-inferior portion of the reconstruction is more of an augmentation. Care should be taken to avoid cutting the iliofemoral ligament more than required and the psoas should not be visualized from the central compartment. In our practice, we have found visualization of the psoas to lead to more tendinitis or psoas tendon fraying postoperatively. For cases where access to the antero-inferior labrum is due to lack of distraction or portal placement, this region can be accessed first through the peripheral compartment with the hip in 40° of flexion. Upon returning to the central compartment, this area is reproducibly accessible. In our opinion, this is far preferable to extending the capsulotomy to the level of the psoas tendon. We do not have the same hesitancy to extend the capsulotomy posteriorly as this is easily repaired and reliably heals without psoas irritation.

Fig. 2.

a Right hip of a 47-year-old woman with posterior superior labral ossification and resultant acetabular overcoverage. Her anterior labrum was not affected and was thus not completely resected. In order to preserve stability of the antero-inferior graft-labral junction and the TAL, the suture from the antero-inferior anchor was first passed around the antero-inferior labrum at the junction with the TAL. The graft was subsequently passed to sit on the articular side of the labrum with and the suture limb sitting outside the labrum was used as the post suture limb and tied to leave the knot outside the joint. b This is effectively an augmentation antero-inferiorly which transitions to a complete labral reconstruction antero-superiorly to posteriorly. Not the anterior capsule/iliofemoral ligament is left intact

The acetabular rim is burred through the length of the planned reconstruction. If pincer-type FAI is present, acetabular osteoplasty is performed at this point. The rim is then burred postero-inferiorly behind the labrum to the 7:30 position. If still in good condition, 1–2 cm of the posterior-inferior labrum is left intact, allowing for fixation of the graft just extra-articular to the native labrum so that there is overlap of the graft and the labrum in an area of low stress. This eliminates the need for cutting excess graft as it will be behind the native labral remnant and extra-articular. In our experience, this portion of the native labrum is usually intact. However, if damaged the labrum should be resected to the TAL postero-inferiorly, this overlapping technique can be extrapolated to shorter grafts when the surgeon prefers a segmental reconstruction. This obviates the need for precise labral defect and graft length measurement. Additionally, we have found that overlap is typically far preferable to suturing the graft to the native labrum posteriorly as this often results in a bunching up at the site of the graft-labral interface which, when viewed with the hip out of traction will sometimes result in a disruption of the suction seal.

After resecting the native labrum, the hip is removed from traction. Traction time for this initial portion of the procedure is typically 15 min, although may be longer depending on the extend of work needed—particularly in the revision setting where sutures are removed and greater dissection is required to separate the capsule from the labrum.

With the hip out of traction, any work needed in the peripheral compartment is completed while the graft is prepared on the back table. In our practice, a frozen tensor fasia lata allograft (Allosource; Centennial, CO, USA) is available for all cases and the decision to proceed with reconstruction is determined intraoperatively. The graft is thawed and soaked in antibiotic solution for 10 min and is then tubularized with 3-0 non-absorbable braided sutures (Stryker; Stryker Sports Medicine, Sunnyvale, CA, USA) to a size of 100-mm length by 6-mm diameter. For smaller acetabula or areas of pathology, 80 mm may be adequate. For larger acetabula, grafts up to 110 mm may be required.

A suture anchor (NanoTack Flex; Pivot Medical Stryker Sports Medicine, Sunnyvale, CA, USA) is placed through a cannula in the AM portal antero-inferiorly adjacent to the TAL. To avoid excess incision to the antero-inferior capsule which separates the psoas from the hip, a smaller curved suture anchor drill guide is preferable. As this technique also minimizes exposure and dissection, knotless suture anchors are disadvantageous in this region. As direct visualization often requires excessive capsular incision, it is important that the surgeon develop a good sense of positioning through tactile feedback and be able to extrapolate anchor placement based on visual and tactile cues. It is important for the surgeon to drill his or her own anchors while the assistant holds the camera and visualizes the articular surface.

One tail of the suture is then passed three times through the end of the graft, which is then shuttled into the joint and tied. The second anchor is placed through the AM portal 0.5–1 cm from the first. Using an atraumatic grasper (Suture Retriever, 10° Up Curved with WishBone Handle. Arthrex; Naples, FL USA), an assistant then holds the graft through the DALA portal in the correct position with tension (Fig. 3). Suture is passed around the graft and tied into place. This process is repeated with 3–4 more suture anchors placed through the AM portal until the graft is secured to the 11 o’clock position postero-superiorly. Care should be taken to position all anchors as close to the articular surface as possible without penetrating it, to ensure that adequate suction seal is restored by the graft. If the angle of drilling/suture anchor placement is suboptimal (i.e., off of the rim), the anchors can easily be placed through the DALA portal which typically addresses this problem.

Fig. 3.

An atraumatic grasper is used by the assistant to holds the graft through the DALA portal in the correct position with appropriate tension while the surgeon ties the suture. This process is repeated for multiple anchors so that the graft position and tension are perfect with each time the sutures are tied

Graft length and tension can then be adjusted to account for up to 20 mm of length inaccuracy through positioning of the postero-inferior (PI) anchor and placement of the length independent graft management anchor (LIGMA). To accomplish this, the posterior point of the graft is positioned into its desired placement (Fig. 4). The PI anchor is then placed through the AL portal. If the graft is short, the PI anchor can be positioned at 8–9 o’clock behind the labral remnant. If the graft is long, it may be positioned inferiorly behind the native labrum as far down as the TAL. The point where the suture from the PI anchor is passed through the graft also serves as an adjustment point. An atraumatic grasper is used to hold the graft through the DALA portal while a penetrating suture retriever (SlingShot Stryker Sports Medicine, San Jose, CA, USA) is used to pass suture through the graft between sutures within the graft which act as rip-stop sutures to ensure that tension is maintained (Fig. 5). The LIGMA anchor is then placed 5–7 mm proximal to the PI anchor through the AL portal to adjust tension. The leading suture tail is placed through the graft and then around the graft under the posterior suture tail, locking in the desired tension. If less tension is required, the leading suture tail may be passed through the graft more distally (i.e., postero-inferiorly). If more tension is needed, the leading suture tail may be passed more proximally (i.e., antero-superiorly) as the graft will be stretched from the point of suture passage towards the position of the anchor when the suture is tied (Fig. 6).

Fig. 4.

An atraumatic grasper is used to place the posterior end of the graft behind the native labral remnant to approximate anchor placement for subsequent fixation. In order to avoid a gap between the graft and the native labrum, the initial postero-inferior resection is conservative as this can be resected after graft fixation. This ensures an overlap of native healthy labrum and the graft postero-inferiorly which will ensure subsequent suction seal restoration

Fig. 5.

An atraumatic grasper is used to hold the graft through the DALA portal while a penetrating suture retriever is used to pass suture through the graft between sutures within the graft which act as rip-stop sutures to ensure that tension is maintained. The point at which the suture is retrieved through the graft can be adjusted to assure appropriate graft tension

Fig. 6.

The lead LIGMA suture is retrieved through the graft. This suture is from the penultimate postero-inferior anchor after the postero-inferior-most anchor has been placed and the graft length established. After this, leading suture is retrieved through the graft it is then passed around the graft postero-inferior to the post and then tied. Tension on the graft can be fine-tuned with this anchor depending on whether the suture is passed a bit more superiorly or inferiorly relative to the anchor

One to three additional anchors are then placed through the AL portal and tied using a simple loop suture technique to close the gap between the front half of the graft and the posterior-inferior portion. Good fixation is then confirmed throughout the length of the graft. The hip is removed from traction and an exam is performed to confirm re-establishment of suction seal and absence of impingement (Fig. 7).

Fig. 7.

Suction seal is checked once the hip is out of traction

Analgesia

Optimal postoperative pain management is of paramount concern. There has been a great deal of research into the ideal analgesic regimen following hip arthroscopy. In the past, we worked closely with our anesthesia colleagues to perform a selective lumbar plexus blockade [36]. We have also previously utilized a fascia lata block. More recently, we have switched to performing an intraoperative pericapsular injection. A recent randomized controlled trial conducted by our team demonstrated equivalent postoperative pain relief with a pericapsular injection when compared to a lumbar plexus blockade, while also obviating the dependence on a qualified anesthesia provider to administer the block [37]. Other modalities reported in the literature include extracapsular local analgesia infiltration [38] and a variety of postoperative intra-articular injections [39–41]. A letter to the editor in response to our pain study suggested that the pericapsular nerve group block and/or shamrock block may be the optimal analgesic intervention following hip arthroscopy; however, there is a noticeable paucity of literature investigating these modalities on patients following arthroscopic surgery on the hip [42, 43].

Rehabilitation

Patients are weight-bearing and range-of motion as tolerated immediately postoperatively. However, crutches are required for at least 4 weeks and patients are instructed to avoid positions of discomfort. In the absence of overzealous early passive stretching or inappropriate exercises, this is easily and predictably accomplished. In our practice, we do not use continuous passive motion machines or bracing. Patients are allowed to progress through activities in a stepwise manner. Slower progressions are employed for patients undergoing certain concomitant procedures, such as chondral restoration or gluteal repair procedures. Our protocol typically permits stationary biking with resistance at 4 weeks, jogging at 12 weeks, and full unrestricted activity at 6 months, although this is individually variable. The hip should not be pushed beyond its comfort zone for the entirety of the recovery and rehabilitation process regardless of external time pressures [44].

Outcomes

Labral reconstruction offers promising outcomes to traditionally difficult-to-treat hip pathologies. Philippon et al. first described favorable results in patients with labral deficiency or advanced degeneration after labral reconstruction in 2010 [11••]. Since then, multiple studies have supported reconstruction as a viable treatment option for severe labral pathology. Mook et al. showed that reconstruction leads to clinically significant improvements in function, pain, and patient satisfaction [45]. White et al. have consistently demonstrated lower failure rates among reconstructed labra than hips treated with labral repair [14,15,16••, 17]. In study of a cohort of athletes, our team noted that all patients included met the substantial clinical benefit and exceeded the minimally clinically important difference from preoperatively to postoperatively. Furthermore, 86.7% returned to play at a median of 6 months [12]. Additionally, Boykin et al. have demonstrated that labral reconstruction leads to improved function and return to play in elite athletes [46].

A 2019 systematic review by Al Mana et al. including 265 hips demonstrated improved short- and mid-term patient-reported outcomes and functional scores postoperatively [47•]. A 2020 systematic review and meta-analysis by Rahl et al. looking at 537 hips also noted that arthroscopic labral reconstruction results in clinically significant improvements in patient-reported outcomes [34]. Most recently, Safran et al. reviewed 7 studies including 228 hips from 197 patients and found that reconstruction produced statistically equivalent postoperative outcome scores and patient satisfaction to labral repair [48]. Due to the novelty of labral reconstruction as a procedure, mid-term outcome data is limited, and long-term data is not available. Future research should include high-quality prospective studies with long-term follow-up measuring both patient-reported and clinician-measured outcome scores.

While reconstruction is often considered in the setting of revision hip arthroscopy, there are emerging data to support its use as a primary procedure. Our team noted similar outcomes when comparing primary circumferential reconstruction and primary repair cohorts despite significantly worse preoperative characteristics within the labral reconstruction group [13•]. In a direct comparison, White et al. observed that hips undergoing primary reconstruction were less likely to fail their index procedure than hips undergoing primary labral repair (0% vs 31% respectively) [16••]. Patient-reported outcome scores were equivalent between reconstructed hips and hips that did not fail treatment in the repair cohort. In another study of patients over 40 years of age, White et al. found that primary reconstruction led to greater average improvement in the pair or debridement [49, 50]. Altogether, these data suggest that primary labral reconstruction may produce good clinical outcomes, particularly in patients with less favorable preoperative demographics [15].

Multiple techniques for labral reconstruction have been described [11••, 12,13•, 14,33•, 51]. Many techniques focus on segmental reconstruction, in which damaged labral tissue is resected back to a stable base and a segmental graft is positioned to fill the defect. More recently, complete reconstruction techniques have been developed [12,13•, 14,51]. While no studies have directly compared segmental reconstruction with complete reconstruction, complete reconstruction is preferred in our practice. Segmental reconstruction may not reliably remove all pain-generating tissue or may leave unaddressed posterior acetabular over coverage or labral ossification or damage. Additionally, junction points between segmental grafts and native labrum are often positioned in areas of high stress. Given that these junctions are inherently weak, we believe that segmental reconstruction may confer less stability and predispose patients to higher risk of graft failure than circumferential reconstruction. The native labrum-graft junction point issue can be exacerbated by graft-defect mismatch. For grafts that are too short, there is a gap which will preclude re-establishment of suction seal. For grafts that are too long, they either must be cut, which will cut the reinforcing sutures of the graft, or the excess length must be maintained in an area which will remain outside of the femoro-acetabular articulation. Our technique provides a standardized approach and solution for every acetabulum and labrum.

Other authors have more recently advocated labral augmentation as a means of preservation of some of the proprioceptive fibers of the labrum [52•, 53]. While Philippon et al. have reported favorable results, there remains the theoretical downside of retention of tissue damaged beyond repair containing nociceptive fibers and the possibility of undertreating acetabular and/or labral pathology. Additionally, in our experience, the suction seal restoration is less predictable with an augmentation than with a complete reconstruction.

Segmental reconstruction and augmentation are likely very good solutions for some hips in the hands of some surgeons, but these techniques are limited by the extent of pathology which can be addressed. They may be suboptimal for more global pathology such as coxa profunda, or where there is extensive labral damage and thus nothing to augment. Our technique for complete reconstruction is attractive as it is relatively standard and reproducible with repetition, providing the surgeon and patients with a predictable result for the treatment of variable pathology. While we certainly do not advocate this technique for every patient or every surgeon, it has, however, been an extremely useful tool to have in our armamentarium.

Conclusion

Hip labral reconstruction is an increasingly utilized technique for repairing the previously irreparable labrum. Reconstruction is performed for labral tears with severe intrasubstance damage, ossification, or segmental defects, particularly in the revision setting after failed previous repairs. While most available literature is observational in design, multiple studies have shown labral reconstruction to lead to clinically significant improvement in pain, function, and patient satisfaction supporting labral reconstruction as a viable arthroscopic treatment option for traditionally difficult-to-treat hip pathology.

Funding

Not applicable

Data availability

Not applicable

Declarations

Conflict of Interest

ABW – Stryker, Allosource – consultant