Labral reconstruction is a type of

hip arthroscopy Hip arthroscopy refers to the viewing of the interior of the acetabulofemoral (hip) joint through an arthroscope and the treatment of hip pathology through a minimally invasive approach. This technique is sometimes used to help in the treatment of ...

in which the patient's native labrum is partially or completely removed and reconstructed using either autograft or allograft tissue. Originally described in 2009 using the ligamentum teres capitis, arthroscopic labral reconstruction using a variety of graft tissue has demonstrated promising short and mid-term clinical outcomes. Most importantly, labral reconstruction has demonstrated utility when the patient's native labral tissue is far too damaged for debridement or repair.

Anatomy

The

acetabular labrum The acetabular labrum (glenoidal labrum of the hip joint or cotyloid ligament in older texts) is a ring of cartilage that surrounds the acetabulum of the hip. The anterior portion is most vulnerable when the labrum tears. It provides an articulat ...

is a fibrocartilagenous structure similar in composition to the

meniscus Meniscus may refer to: *Meniscus (anatomy), crescent-shaped fibrocartilaginous structure that partly divides a joint cavity *Meniscus (liquid) The meniscus (plural: ''menisci'', from the Greek for "crescent") is the curve in the upper surface ...

. It is a ring of tissue that surrounds the

acetabulum The acetabulum (), also called the cotyloid cavity, is a concave surface of the pelvis. The head of the femur meets with the pelvis at the acetabulum, forming the hip joint. Structure There are three bones of the ''os coxae'' (hip bone) that c ...

of the pelvis, and allows the head of the

femur The femur (; ), or thigh bone, is the proximal bone of the hindlimb in tetrapod vertebrates. The head of the femur articulates with the acetabulum in the pelvic bone forming the hip joint, while the distal part of the femur articulates with ...

to articulate smoothly and efficiently with the acetabulum. The labrum plays an important role in maintaining the biomechanical stability of the hip joint. Studies have shown that damage to the labral tissue can result in disruption of the labral suction-seal, a fluid force paramount in maintaining hip joint integrity. An intact labrum also helps to buttress the hip joint to distraction forces. The labrum, when damaged, is also a pain generator, due to a large concentration of type II pain-associated free nerve endings found throughout the tissue, most pronounced at the labral base. Gray342

History

Labral reconstruction was first described in 2009 by Sierra et al. The procedure described in their article described reconstructing a patient's native labrum with a ligamentum teres capitis graft. This was done in the setting of an open surgical hip dislocation. Prior to the introduction of labral reconstruction, complex labral tears were often treated with removal of damaged tissue (debridement) or focal repair. The applicability of these methods to severe or widespread labral damage is less than ideal. Since then, surgeons have reported on a variety of graft choices and surgical techniques, and an

arthroscopic Arthroscopy (also called arthroscopic or keyhole surgery) is a minimally invasive surgical procedure on a joint in which an examination and sometimes treatment of damage is performed using an arthroscope, an endoscope that is inserted into the jo ...

approach has usurped open dislocation, due to fewer complications, a lower need for revision surgery and quicker recovery time.

Indications

Labral reconstruction, while still a relatively novel technique, has demonstrated utility and efficacy in treating labral tears in patient's whose native labral tissue is far too damaged for arthroscopic debridement or repair. It is most often utilized in order to surgically correct the damage resulting from

femoroacetabular impingement Femoroacetabular impingement (FAI) is a condition involving one or more anatomical abnormalities of the hip joint, which is a ball and socket joint. It is a common cause of hip pain and discomfort in young and middle-aged adults. It occurs when th ...

(FAI), a condition in which the femoral head articulates imperfectly with the acetabular cup. Labral damage resulting from FAI or other conditions exists on a spectrum, with varying degrees of labral damage necessitating different surgical management. The most mild degrees of labral damage can be managed with arthroscopic debridement, a procedure in which the damaged tissue is excised with an arthroscopic shaver or electrocautery device. More moderate damage responds better to arthroscopic labral repair, a procedure in which surgical anchors are drilled into the bony acetabular rim and sutures are used to reapproximate the damaged labral tissue. The most severe degrees of labral pathology is often unresponsive to labral repair, with damage far too diffuse for focal debridement. In these cases, labral reconstruction is the best option for not only restoring the biomechanics of the acetabular labrum, but for treatment of the patient's pain. Femoral acetabular impingement FAI de

A recent multicenter epidemiological study found that the majority of patients undergoing labral reconstruction are middle-aged females whose pain is localized around the groin. Patient pain is ofter exacerbated by sitting and athletic activities. Many patients undergoing labral reconstruction have failed conservative therapy, which typically includes intra-articular injections and physical therapy. A majority of patients have abnormal acetabular or femoral bony morphology typical of

(FAI).

Technique

Graft selection

A variety of graft options for labral reconstruction have been proposed. Although the literature for ACL

reconstruction Reconstruction may refer to: Politics, history, and sociology *Reconstruction (law), the transfer of a company's (or several companies') business to a new company *'' Perestroika'' (Russian for "reconstruction"), a late 20th century Soviet Unio ...

has demonstrated more favorable outcomes with

autograft Autotransplantation is the transplantation of organs, tissues, or even particular proteins from one part of the body to another in the same person ('' auto-'' meaning "self" in Greek). The autologous tissue (also called autogenous, autogene ...

tissue versus

allograft Allotransplant (''allo-'' meaning "other" in Greek) is the transplantation of cells, tissues, or organs to a recipient from a genetically non-identical donor of the same species. The transplant is called an allograft, allogeneic transplant, o ...

, no such relationship has been found to exist for labral reconstruction. Drs. Brian White and Andrew Wolff, two sports medicine trained surgeons specializing in hip arthroscopy, both prefer the utilization of allograft tissue. The surgeons who advocate for the use of allograft tissue feel that the control over graft thickness, consistency and size, in addition to the absence of donor site morbidity make it the preferred graft choice for this procedure. Other graft options include

iliotibial band The iliotibial tract or iliotibial band (ITB; also known as Maissiat's band or the IT band) is a longitudinal fibrous reinforcement of the fascia lata. The action of the muscles associated with the ITB (tensor fasciae latae and some fibers of glu ...

autograft,

hamstring In human anatomy, a hamstring () is any one of the three posterior thigh muscles in between the hip and the knee (from medial to lateral: semimembranosus, semitendinosus and biceps femoris). The hamstrings are susceptible to injury. In quadrupeds, ...

s autograft or

quadriceps tendon In human anatomy, the quadriceps tendon works with the quadriceps muscle to extend the leg. All four parts of the quadriceps muscle attach to the shin via the patella (knee cap), where the quadriceps tendon becomes the patellar ligament. It attach ...

autograft. Currently, there is a lack of sufficient data to claim one graft choice superior to the others.

Segmental vs. circumferential/front-to-back

Traditionally, only the damaged labral tissue was resected, and the graft was attached to both the acetabulum and the native labral tissue. This method demonstrated superiority over straight debridement in the treatment of irreparable labral tears. There was concern by some surgeons, however, that the junction points between the native labrum and graft were inherently weak, and thus prone to failure. There was also concern that despite resection of the visibly damaged tissue there existed the possibility for underresection, which could lead to persistent pain despite restoration of the labral biomechanics. Recently, surgeons have begun experimenting with circumferential (front-to-back) reconstruction in which the entirety of the native labral tissue is debrided, and the labrum is completely reconstructed. This technique has shown promising outcomes when utilized in patients whose native labral tissue is far too damaged for repair or debridement. A recent study comparing primary labral reconstruction versus primary labral repair demonstrated higher failure rates in the repair cohort versus the reconstruction cohort.

Outcomes

Arthroscopic labral reconstruction has demonstrated favorable outcomes, which have become more pronounced as techniques and technology continue to develop. Arthroscopic labral reconstruction has shown comparable outcomes to labral repair, despite the fact that those patients who undergo reconstruction typically have far more severe labral damage. Recent studies have shown not only equivalent outcomes between labral reconstruction and labral repair, but improved outcomes for labral reconstruction for patients with more moderate degrees of labral damage. Labral reconstruction also has proven utility in the hips of elite athletes and other high-demand patients.

Complications

The complications encountered during and after labral reconstruction are similar to arthroscopic procedures involving the hip.

Anesthetic complications

Anesthetic complications are rare, but include urinary retention, gastrointestinal upset, cardiac complications and even death.

Operative complications

As with all surgery, arthroscopic labral reconstruction has a small risk of

infection An infection is the invasion of tissues by pathogens, their multiplication, and the reaction of host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmissible disease or communicable dise ...

. Damage to the surrounding neurovasculature is possible, but this risk is minimized through meticulous surgical technique. The most commonly injured nerve is the lateral femoral cutaneous nerve, although this risk is very low with proper

portal placement. A new postless

table Table may refer to: * Table (furniture), a piece of furniture with a flat surface and one or more legs * Table (landform), a flat area of land * Table (information), a data arrangement with rows and columns * Table (database), how the table data ...

Stryker The Stryker is a family of eight-wheeled armored fighting vehicles derived from the Canadian LAV III. Stryker vehicles are produced by General Dynamics Land Systems-Canada (GDLS-C) for the United States Army in a plant in London, Ontario. It ...

has nearly eliminated the risk of postoperative saddle parasthesia, which was previously a common complication. Post-operative

deep-vein thrombosis Deep vein thrombosis (DVT) is a type of venous thrombosis involving the formation of a blood clot in a deep vein, most commonly in the legs or pelvis. A minority of DVTs occur in the arms. Symptoms can include pain, swelling, redness, and enla ...

is also possible, but the rate of this complication can be minimized through the use of blood thinning medications and early ambulation.

References

{{Reflist Orthopedic surgical procedures