Workin’ 9 to 5: Reproducible Acetabular Labral Reconstruction

Video Transcript

In this video, we will describe a methodical and reproducible technique for partial circumferential acetabular labral reconstruction.

As an overview, we will discuss the indications for labral reconstruction, briefly discuss different varieties of labral reconstruction techniques, give a patient presentation, and lay out an in-depth description of our labral reconstruction technique.

Background and Indications

It is important to state that labral repair remains the standard of care for hip labral pathology in 2025. The literature tells us that repair performs better than resection biomechanically and has superior outcomes to debridement, with high rates of healing and return to play. This has been shown in multiple studies that included outcomes over 5 years in length.^1-4 There are, however, circumstances in which labral repair is either not feasible or perhaps a lesser option. These situations include patients with a hypoplastic labrum, in which repair may compromise an already tenuous femoroacetabular suction seal; patients with ossification of the labrum; patients with irreparable tears in which the tissue is too frayed to hold a suture; or patients who have failed prior labral repair. These circumstances can be challenging, and labral debridement alone has failed to provide acceptable outcomes on a long-term basis. Therefore, labral reconstruction, or replacing the native labrum with allograft tissue, serves as an enticing option for these complex situations.

Labral reconstruction has several advantages over labral repair. First, the quality of the native labral tissue is inconsequential, as it is removed during the procedure. Labral reconstruction has been shown to improve on the native suction seal. It removes the native pain fibers and allows for comprehensive rim correction, particularly in the setting of labral ossification. Despite these advantages, it is difficult, requires increased time and expense, and requires either a skilled assistant or a pre-prepared graft. Lastly, labral reconstruction is often a game-time decision based on the intraoperative labral evaluation, and scrutiny of preoperative images is warranted to ensure the operating room is prepared.

Segmental versus circumferential reconstruction techniques are often debated. Segmental reconstruction preserves the healthy labrum, is technically easier, and requires less traction time, but it requires precise graft sizing and leads to a discontinuity of the circumferential labral fibers. ⁵ Circumferential reconstruction removes all possible pain fibers and is a continuous graft without a side-to-side anastomosis, but it is technically challenging. ⁶

Thus, we present our preferred labral reconstruction technique, which is a partial circumferential reconstruction from 9 to 5 o'clock on the acetabular clock face. This construct is the best of both worlds—a repair with no anterior anastomosis, intact circumferential labral fibers at the most stressed areas, and graft length can be adjusted after graft insertion.

The patient to discuss is a 44-year-old woman with worsening right hip pain despite physical therapy and an intra-articular steroid injection. She has a surgical history of 2 prior hip arthroscopies, 11 and 6 years prior. On examination, she has pain with flexion, adduction, and internal rotation but otherwise no abnormal findings.

Her anteroposterior pelvis radiograph demonstrates labral ossification with a lateral center edge angle of 48° and a well-preserved joint space. A 45° Dunn lateral shows no residual CAM deformity, with an alpha angle of 47°. A false profile radiograph also shows anterior labral ossification, with an anterior center edge angle of 48°.

Coronal and sagittal magnetic resonance imaging sequences show labral ossification, a chronic capsular defect, and recurrent labral tearing. This is confirmed on an axial oblique sequence.

Technique Description

The patient is positioned on a postless traction pad with the operative hip close to the edge of the bed.

The portals used for this labral reconstruction case include the standard anterolateral, mid-anterior, and distal anterolateral portals. Additionally, a posterolateral portal is utilized for graft passage, and an anterior suture management portal is used.

The labrum is first evaluated. In this case, the labrum has ossified and is therefore firm to palpation with the probe. A radiofrequency device is used to expose the rim and reveal the diminutive and irreparable remaining labral tissue. The rim is prepared circumferentially with a high-speed bur, and any remaining nonviable labral tissue is debrided in preparation for allograft labral reconstruction.

We begin with the placement of a 5:30 anchor. Viewing from the anterolateral portal and working from the mid-anterior portal, a curved guide is used to deploy an anchor with a single sliding suture. The 2 suture limbs are parked in the mid-anterior portal.

Next, working through the distal anterolateral accessory (DALA) portal, we will place 3 knotless all-suture anchors in the rim at approximately the 3, 1, and 11 o'clock positions.

Suture management is critical. The blue working suture from all 3 knotless anchors is kept in the DALA portal. The 3 white shuttling sutures are all brought out through a percutaneous suture management portal and parked. Here you can see the 3 knotless working sutures in the DALA portal, the 3 knotless shuttling sutures in the suture management portal, and the 2 suture limbs from the 5:30 anchor in the mid-anterior portal.

Next, working from the posterolateral portal, we will retrieve 1 limb of the 5:30 anchor. This limb is passed between the knotless working sutures and the knotless shuttling sutures and is retrieved out of the posterolateral portal. This sawbones model illustrates the desired suture configuration, with 1 limb of the 5:30 anchor resting between each of the knotless sutures.

We are now ready to shuttle our graft into the hip joint. We will suture the graft to the suture limb from the 5:30 anchor that is currently positioned in the posterolateral portal. The other end of that suture, currently placed in the mid-anterior portal, will then be pulled, and the graft will be inserted into the joint between each knotless suture.

We are using a pre-prepared 10 cm in length fascia lata graft. Using a free needle, the suture limb in the posterolateral portal is secured to the graft with multiple passes. Once secured, the other suture limb from the 5:30 anchor is pulled, and the graft is shuttled into the joint. An atraumatic grasper is used as needed to ensure that the graft passes appropriately between all the knotless sutures. The graft is tensioned and secured to the 5:30 anchor by tying arthroscopic knots.

Next, the rest of the graft is secured by retrieving the knotless sutures and their respective shuttling sutures out of the DALA portal. Each suture is deployed through its respective anchor and tensioned. At this point in the case, if needed, additional anchors may be placed and the graft secured to additional points of fixation with a technique similar to a standard labral repair.

While viewing from the mid-anterior portal and working from the posterolateral portal, the graft can then be secured to the native posterior labrum. An anchor with 1 sliding suture is placed at the 9 o'clock position. One limb of suture from the anchor is then passed through the graft and tied. For additional fixation and completion of the posterior anastomosis, the suture is then passed a second time around both the graft and around the native labrum. It is tied once again.

Excess graft is then cut and removed.

Our final construct is now complete with excellent restoration of labral anatomy. Upon testing, the suction seal has been restored. The capsule is then closed in the standard fashion.

This sawbones model will once again demonstrate our preferred technique for acetabular labral reconstruction. The graft is shuttled in from the posterolateral portal between 3 knotless all-suture anchors. It is secured first at the 5:30 position, and then the working suture from each knotless anchor is deployed and tensioned. Posterior fixation is achieved by placing an anchor with 1 sliding suture, passing 1 limb of this suture through the graft, tying this down, then making a second pass around both the graft and native labrum before tying a second time. At this point, additional anchors may be used in a similar fashion to labral repair if additional fixation is needed. The construct is complete with reconstruction from the 9 to 5 o'clock position.

It is important to allow the knotless sutures to reduce the graft to the rim and pass your anastomosis sutures both around and through the graft. Do not trim the suture tail attached to the graft too short, as you will not be able to retrieve excess graft at the end of the case. Lastly, do not pull the graft quickly into the joint and ensure correct alignment between the sutures from the knotless anchors.

All patients are instructed to perform partial weightbearing with crutches for 4 weeks and are given naproxen twice daily for heterotopic ossification prophylaxis. Postoperative physical therapy is conducted in 4 phases, with running and sport-specific exercises not beginning until at least 3 months postoperatively. Return to sports criteria include a full pain-free range of motion, symmetric hip strength, and the ability to perform sport-specific exercises without pain.