Labral Reconstruction

Labral reconstruction replaces nonfunctional acetabular labral tissue with a graft. The goal is to recreate a stable labral rim that contacts the femoral head and restores the suction seal, fluid pressurization, and stability provided by a healthy native labrum

Typical indications include an irreparable or severely degenerative labrum, extensive calcification or ossification, a hypoplastic or otherwise nonfunctional labrum, and deficient tissue after prior debridement or failed repair. It is particularly useful in revision hip arthroscopy.

Reconstruction strategies:

Reconstruction can replace only the irreparable segment or most of the acetabular labrum. The choice depends on how much healthy, functional labrum remains. In segmental reconstruction only the deficient segment is excised and replaced with graft. This method preserves the healthy parts of the native labrum. In total reconstruction most or all the labral tissue is excised and replaced. This strategy is useful when little to no health labrum remains.

Graft choice:

Both autograft and allograft can be used. Commonly used grafts include iliotibial band, hamstring tendons, and tibialis anterior/posterior tendons. Both auto and allograft can be successfully used, and the choice is often dependent on patient factors, reconstruction techniques, and tissue availability.

General steps:

1. Assess the labrum and define the reconstruction

Probe the entire labrum before removing tissue. Determine which portions are functional and which are irreparable. In a segmental reconstruction, mark the transition from healthy to irreparable tissue at both ends.

2. Remove irreparable tissue and prepare the rim

Excise only the labral tissue that will be replaced. For a segmental reconstruction, preserve healthy native labrum at both ends and create clean transition points. Clear soft tissue from the adjacent acetabular rim so the graft can lie directly against bone and anchors can be placed safely.

3. Plan anchor positions and graft length

Plan fixation along the entire defect before introducing the graft. Anchors are commonly placed at 8-10 mm intervals, although spacing varies.

Graft length can be measured directly, estimated from the planned anchor positions, or an intentionally long graft can be used and then trimmed after fixation. This method reduces the risk of preparing a graft that is too short.

4. Prepare the graft

The graft should be prepared with a diameter that approximates the native labral diameter and allows it to contact the femoral head without overstuffing the joint. Fascia-based grafts need to be folded or rolled and sutured into a tubular construct while tubular tendon grafts sometimes closely approximate the labral diameter already. The ends should be whip-stitched or otherwise controlled during graft passage.

5. Introduce and dock the graft

The graft is brought into the central compartment through a cannula or enlarged working portal. One end is docked at the terminal anchor and the remaining graft is controlled with a grasper or traction suture while fixation proceeds. Graft management can be challenging due to twisting, bunching, and snagging of the graft.

6. Fix the graft sequentially to the acetabular rim

Progress from the first terminal anchor across the reconstruction, keeping the graft reduced against the rim. Sutures may pass around the graft (loop sutures) or through it (mattress sutures) depending on the anchor system and technique. Both knotted and knotless anchors can be used. A more detailed discussion of suture and anchor types is included in the section on labral repair.

An important technical aspect of graft fixation is ensuring appropriate tension to prevent redundancy or the graft everting after fixation. Once the final anchor is placed, excess graft should be excised to prevent overstuffing of the joint.

7. Assess the reconstruction

Probe the graft to confirm stable fixation and inspect the acetabular cartilage for drill or anchor penetration. Release traction and watch the femoral head reduce into the acetabulum. The reconstructed labrum should contact the femoral head and recreate a continuous suction seal without folding or everting.

Common technical problems

1. Graft twisting

A twisted graft will prevent a proper recreation of labral seal. Control of both ends of the graft will prevent graft twisting during fixation.

2. Poor anchor angle

Drilling too close to the articular surface can penetrate acetabular cartilage. To avoid this visualize cartilage while drilling and use fluoroscopy as needed.