Labral Pull-Through Technique for Arthroscopic Labral Reconstruction of the Hip

Abstract

Background:

The goal of hip labral reconstruction is to restore the suction seal, requiring the labral graft to be precisely secured along the acetabular rim. When performed arthroscopically, controlling the graft as it is suspended in the hip joint between 2 cannulas can be challenging, making fixation in the optimal position to restore the suction seal difficult to achieve.

Indications:

Labral reconstruction/augmentation is indicated for patients with a deficient/dysfunctional labrum when repair alone cannot restore/maintain the suction seal.

Technique Description:

Following diagnostic arthroscopy, debridement, and measurement of the labral deficiency (30 mm), 70 mm tibialis anterior allograft was tubularized with a whipstitch and prepared with long suture tails at both ends and a single mattress stitch placed through the graft at the medial end. Holes for the anchors were pre-drilled. Viewing from the anterolateral portal, the graft was introduced down a sled through the modified anterior portal, pulled through the joint, and guided into the posterolateral portal cannula via instrumentation through the distal anterolateral accessory portal. With initial fixation achieved medially with the mattress stitch, directing the graft into position while achieving optimal coverage of the deficient area was facilitated by the excess graft length pulled into the posterolateral portal cannula.

Results:

Labral reconstruction can restore the suction seal of the hip joint when repair alone is not sufficient. Comparative studies with matched repair cohorts have demonstrated comparable survivorship and patient-reported outcomes between groups, with similar rates of patient acceptable symptomatic state and minimal clinically important difference between groups, and similar rates of return to sport in high-level athletes. Recent systematic reviews have largely corroborated these findings.

Discussion/Conclusions:

Arthroscopic labral reconstruction is an effective treatment option when repair alone cannot restore the suction seal when the graft is secured in an optimal position, but controlling the graft during passage and fixation while achieving a final length spanning the segmental deficiency in continuity with native tissue at both ends can present technical challenges. The labral pull-through technique greatly facilitates this process.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

Labral Pull-Through Technique for Arthroscopic Labral Reconstruction of the Hip.

We demonstrate this technique through an illustrative case and discuss preoperative planning, key surgical steps, and postoperative protocols, concluding with a review of outcomes from the relevant literature.

Labral reconstruction is indicated for patients with a deficient or dysfunctional labrum when repair alone is not capable of restoring and maintaining the suction seal, and in whom a strategy of hip preservation is otherwise clinically appropriate. This may include tears with poor tissue quality incapable of healing, a hypoplastic labrum, labral deficiencies (iatrogenic or otherwise), following excision of a large symptomatic os, or when extensive calcifications are present. The authors prefer repairing the native labrum whenever possible, and in some of these situations repair with allograft augmentation can be performed instead of reconstruction. If a reconstruction is performed, a segmental approach is favored, preserving areas of the native labrum which are uninjured or amenable to repair.

The patient in this case is a 40-year-old woman with recurrent left hip pain and a history of left hip arthroscopic labral repair at an outside institution 4 years prior to this presentation. She did well after her initial surgery and experienced several years of symptomatic resolution, but her groin pain gradually returned, resulting in functional limitations despite exhaustive conservative measures.

Examination was consistent with femoroacetabular impingement and recurrent labral tear.

On upright weightbearing anteroposterior radiograph, the lateral center-edge angle measured approximately 37°, and the alpha angle measured approximately 50°.

The alpha angle on the Dunn lateral was approximately 53°.

A false profile view was also obtained.

As previous authors have observed, magnetic resonance (MR) imaging is useful for ruling out other conditions.

Given this patient’s history, MR arthrogram was performed, which demonstrated a recurrent labral tear, and she opted to proceed with revision arthroscopy.

A careful review of preoperative imaging is essential to detect conditions that may require augmentation or reconstruction. When such findings are present, the patient is appropriately counseled, and the availability of all anchors, grafts, and other necessary materials and equipment is verified. Surgery is performed on an outpatient basis under general endotracheal anesthesia with paralysis, which is needed to facilitate traction to distract the hip joint. The authors do not use any regional blocks.

Distraction is achieved with a postless table system, and tibialis anterior allograft is typically used when augmentation or reconstruction is indicated by intraoperative findings.

In the pull-through technique, a graft with excess length is prepared with whipstitches on both ends, and a single mattress suture is placed through the graft at what will be its most medial aspect once implanted. While the remainder of the securing sutures will be looped around the graft, the mattress technique for the medial anchor makes initial fixation easier, as a free-floating graft suspended between cannulas is otherwise a moving target. Viewing from the anterolateral portal, the graft is introduced through a modified anterior portal and pulled through with the excess length exiting the posterolateral portal. In the following case, the segmentally deficient area of the acetabulum was approximately 30 mm, so the graft was prepared to a length of 70 mm.

Following routine arthroscopic instrumentation and creation of a standard interportal capsulotomy, diagnostic arthroscopy revealed complex segmental labral tearing with poor quality tissue that was not amenable to repair due to extensive calcification. Probing of the acetabular cartilage demonstrated a wave sign but otherwise no acetabular defects, although focal cartilage injury was seen on the femoral head.

A minimal debridement of the soft tissue between the labrum and the capsule was performed with electrocautery, and a traction stitch was placed through the acetabular capsular leaflet with the Stryker SlingShot device to facilitate visualization.

The irreparable segment of the torn labrum was debrided with shaver and electrocautery to expose the bony rim and allow visualization of any remaining pincer or subspine impingement. The electrocautery device is used to finish the debridement and achieve stable edges of a healthy labrum for the reconstruction.

Acetabular osteoplasty was carried out with the bur to eliminate pincer impingement and prepare a bony bed for the reconstruction, conducive to healing. The subspine region was also addressed. The deficient area in this case measured approximately 30 mm, and a 70-mm graft was prepared and implanted. The benefit of the pull-through technique is that excess graft is simply trimmed after fixation with the final anchor. Between 1 and 2 cm of excess graft is sufficient to use the pull-through technique in most cases.

Holes for the Cynch-Lok (Medline; Northfield, IL) anchors are predrilled with appropriate spacing prior to passage of the graft.

To optimize spacing while guaranteeing fixation at the medial and lateral extent of the reconstruction, it may be helpful to drill the most medial and lateral holes first, drilling additional holes in between according to the space remaining.

Here, the anterior tibialis allograft is shown ready for implantation with the anterior medial end facing the top of the screen. A Stryker X-braid (Kalamazoo, MI) suture has been placed through this end of the graft to allow initial fixation in a mattress configuration.

The graft has been tubularized with a whipstitch with high-tensile nonabsorbable loop suture. Additional X-braids are placed at both ends for shuttling.

Reconstruction is now performed with the pull-through technique. The animation in the upper right corner of the screen provides a global perspective throughout this technical demonstration. Viewing from the anterolateral portal with Stryker Transport cannulas in the distal anterolateral accessory (DALA) and posterolateral portals, a sled is placed through the modified anterior portal. The suture tails from the lateral end of the graft are delivered down the sled into the joint and retrieved through the posterolateral portal cannula.

An instrument placed through the DALA portal can facilitate passage by providing a fulcrum and maintaining a trajectory of pull that is straight off the sled down into the joint. Once the lateral end of the graft enters the joint down the sled, an instrument through the DALA portal can then be used to guide this end of the graft into the cannula in the posterolateral portal. At this point, the labral graft is shuttled from the modified anterior portal down the sled, through the joint, and out through the cannula in the posterolateral portal, until the medial end of the graft with the mattress suture enters the joint.

The mattress suture is then loaded into a Cynch-Lok anchor and secured in the most medial hole, and fixation proceeds from medial to lateral. Additional sutures are passed around the graft, loaded into additional anchors, and secured in the remaining holes. Appropriate positioning and tensioning of the construct during fixation is maintained with the excess graft through the posterolateral portal cannula. Once the lateral-most anchor has been placed, any graft extending beyond the reconstruction is simply cut and removed. The arthroscopic electrocautery device is typically used to trim the excess graft and create a stable transition to the healthy normal labrum.

The final construct is probed for stability, and traction is released to confirm restoration of the suction seal.

Femoral osteoplasty was performed under fluoroscopic guidance.

Complete closure of the interportal capsulotomy was achieved with 3 high-tensile strength nonabsorbable sutures. These sutures were passed with the Stryker SlingShot device and secured with sliding-locking knots. Capsular closure has been associated with superior outcomes, and persistence of capsular defects can be associated with microinstability. Repairing the capsule therefore represents a key surgical step that should not be neglected.

Diligent planning and methodical technique can help avoid several pitfalls during reconstruction.

Several key pitfalls and pearls are summarized on this slide. Additional tips and tricks include drilling the medial and lateral anchor holes first and then drilling the remaining holes in between to optimize the spacing while ensuring fixation at the ends of the graft and to target about 1 to 2 cm of excess graft length to have enough extra graft to pull into the posterolateral cannula. This is more of a concern for larger defects where more of the initial graft length will remain implanted.

These immediate postoperative precautions are maintained for the first 4 weeks.

The rehabilitation protocol is divided into 4 phases: phase 1, the immediate postoperative protective phase; phase 2, the intermediate moderate protection phase; phase 3, the advanced exercise phase; and phase 4, the return to activity phase.

Boykin and colleagues ¹ reported results of labral reconstruction in 21 elite athletes and noted significant improvement in modified Harris Hip Score and Hip Outcome Score–Sport-Specific Subscale, with 81% of athletes able to return to play at the same level. Two subsequent studies comparing results of reconstruction with repair found comparable survivorship and patient-reported outcomes, and similar rates of patient acceptable symptomatic state and minimal clinically important difference (MCID) between groups.

Similar rates of return to sport between reconstructions and matched repairs have been reported in high-level athletes. Recent systematic reviews largely corroborate these findings. Trivedi and colleagues ³ observed that among the studies included in their analysis, all of which reported at least 1 validated outcome instrument, improvement consistently exceeded MCID. Rahl and colleagues ² did not detect any effect of graft choice on reconstruction outcome, and both studies estimated similar rates of revision and subsequent arthroplasty.