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Labral Base Refixation in the Hip: Rationale and Technique foran Anatomic Approach to Labral Repair

Robert Fry, M.D., and Benjamin Domb, M.D.

Abstract: Recent literature has defined the importance of anatomic repair in shoulder and knee arthro-scopy. New advances in hip arthroscopy have created opportunities to apply the principle of anatomicrepair to the hip. To address the obstacles in the restoration of labral anatomy, we describe an anatomicapproach to labral refixation. We reviewed the literature on biomechanics of the labrum to identify thefactors that are essential to the function of the labrum. Existing techniques for arthroscopic labral repairand potential challenges in restoration of labral anatomy were reviewed. A list of criteria for anatomiclabral repair was created, and a technique for anatomic labral base refixation was developed. Thetechnique incorporates the understanding of the function and biomechanical role of the labrum and buildson existing techniques to fulfill the criteria for restoration of anatomy. Our purpose was to review theanatomy, biomechanics, and existing repair techniques of the labrum, as well as to describe the rationaleand surgical steps for anatomic labral base refixation in the hip.

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estoration of anatomy has become increasinglyrecognized as an essential principle of successful

rthroscopic surgery. The trend toward restoration ofnatomy has guided the development of techniques fornatomic repairs in the knee and shoulder, such as trans-sseous equivalent rotator cuff repair and anterior cruci-te ligament footprint reconstruction.1-9 With the recentdvances in our understanding of hip arthroscopy andechnologic advances, new opportunities are arising topply the principle of anatomic repair to the hip.

From the Department of Orthopedics, Loyola University Medi-al Center, Maywood, Illinois, U.S.A.B.D. received support from Arthrex, Naples, FL, exceeding the

quivalent of US $500 related to this research.Received December 8, 2009; accepted January 21, 2010.Address correspondence and reprint requests to Robert Fry,.D., Department of Orthopedics, Loyola University Medical Cen-

er, 2160 S First Ave, Maguire Center, Ste 1700, Maywood, IL0153, U.S.A. E-mail: robfry30@gmail.com© 2010 by the Arthroscopy Association of North America0749-8063/9719/$36.00doi:10.1016/j.arthro.2010.01.021

Note: To access the video accompanying this report, visit

ethe September supplement issue of Arthroscopy at www.arthroscopyjournal.org.

Arthroscopy: The Journal of Arthroscopic and Related Surgery

RATIONALE FOR ANATOMIC LABRALREPAIR

The importance of restoration of anatomic foot-rints in the shoulder and knee has been highlighted inrthroscopy.10 Carrying this principle into the hip, itas been suggested that arthroscopic treatment ofemoroacetabular impingement (FAI) should also aimo restore normal anatomy.11 Labral tears in FAI occurs a result of cam, pincer, or combined impinge-ent.12 Correction of bony impingement may require

steoplasty of the cam lesion or acetabuloplasty of theincer lesion. To perform acetabuloplasty while pre-erving the labrum, it is often necessary to detach theabrum before rim trimming. This technique requiresubsequent arthroscopic refixation of the labrum so aso restore its native anatomy. It is theorized that suchestoration of anatomy and resolution of impingementay prevent degeneration of the joint.12

According to a 2008 meta-analysis, open surgicalislocation for treatment of FAI and associated labralears yields good to excellent results in 65% to 90% ofatients (mean follow-up, 40 months) versus good to

xcellent results in 67% to 93% after arthroscopic

S81, Vol 26, No 9 (September, Suppl 1), 2010: pp S81-S89

mailto:robfry30@gmail.comhttp://www.arthroscopyjournal.orghttp://www.arthroscopyjournal.org

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anagement of FAI (mean follow-up, 2 years).13 At0 years’ follow-up, Byrd and Jones14 reported suc-essful outcomes in 82% of patients without arthritist the time of arthroscopic labral debridement. Despiteositive results with labral debridement and resection,lucidation of labral biomechanics has shifted empha-is to labral preservation. Preservation of the labrumay necessitate labral refixation, particularly when

he labrum is detached for the acetabuloplasty. Espi-osa et al.15 reported improved clinical outcomes withabral refixation versus resection with acetabuloplastyor FAI. More recently, favorable results have beeneported with arthroscopic labral repair and treatmentf FAI.16-20

The labrum is thought to be important in multiplespects of the biomechanics of the hip, includingegulation of flow of synovial fluid, maintenance ofhe suction seal, stability, and load bearing.21-25 Bio-echanical studies have suggested that a functional

abrum slows cartilage consolidation through its hydro-tatic effects and therefore may serve a protective role forhe articular cartilage.24 Regulation of fluid flow and

aintenance of the suction seal can only occur whenemoral head contact is preserved in all parts of theabrum. The importance of the contact fit between theemoral head and labrum was emphasized by Fergu-on et al.24 When using arthroscopic techniques forabral refixation, surgeons are faced with the challengef restoring the native anatomy of the labrum, as wells its contact with the femoral head, to successfullye-create its functionality.

CURRENT LABRAL REPAIR TECHNIQUES

Labral repair techniques have been described in theiterature using suture anchors, screw anchors, andxtra-articular sutures.26-30 The anchors are placed aslose as possible to the acetabular rim without pene-rating the articular surface. A cadaveric study definedsafe zone for anchor insertion of 2.3 to 2.6 mm from

he rim with an anchor angle of 10°.31 When one isssessing the labrum for repair, the degenerative tissueust first be debrided. Recent repair descriptions em-

hasize preserving as much healthy labral tissue asossible to maintain anatomic function.26 Althoughpen labral refixation as described by Ganz32 gener-lly involved passage of sutures through the labrum,ost arthroscopic labral repair techniques previously

escribed in the literature use simple stitches loopedround the labrum (Fig 1).11,27,29

There are several specific obstacles to restoration of

abral function. Although the looped simple stitch a

echnique can achieve fixation of the labrum to thecetabular rim, the labrum may be bunched and itsormal triangular cross-sectional anatomy may be dis-orted (Fig 2A). The labrum may also be everted awayrom the femoral head, and thus the contact of theabrum with the femoral head may not be reproducedFig 3).24 To address these problems, labral repairith vertical mattress sutures has also been report-

d.26,28,30 However, it has been suggested that punc-uring the labrum with a penetrating instrument shoulde avoided because this may split or tear the labrumnd possibly compromise the suction seal (Fig 4).26

he modes by which labral repair may fail to restoreull contact with the femoral head are summarized inable 1.

SURGICAL TECHNIQUE: LABRAL BASEREFIXATION

Through consideration of the anatomic features ofhe labrum and its biomechanical significance, wedentified 6 major goals of labral repair (Table 2). Aurgical technique for arthroscopic labral base refix-tion (LBR) was developed to meet these 6 goals.he LBR technique incorporates previous outstand-

ng landmark work that has defined the native anat-my and biomechanical importance of the labrum,

IGURE 1. Arthroscopic labral repair with simple looped sutureechnique of left hip viewed from anterolateral portal in supineosition. Although the repair achieves approximation of the labrumL) to the acetabular rim (A), it is bunched into a cylindrical shape,ailing to reproduce the native triangular cross-sectional shape.FH, femoral head.)

s well as the clinical implications of labral preser-

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ation.13,15,26,28,33-36 To achieve restoration of theunctional anatomy of the labrum, the procedureuilds on the pioneering advances in technique byther authors who have made arthroscopic labral re-air technically feasible.15,26,27,29,33,37 The purpose ofhis article is to describe the biomechanical rationalend critical steps for successful use of the LBR tech-ique.

™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™IGURE 2. (A) Labral repair with a simple looped stitch thatasses over the free edge of the labrum (L), causing bunching ofhe labrum and distortion of the normal triangular cross-sectionalnatomy of the labrum. The labrum is bunched and everted awayrom the femoral head (FH), disrupting the contact seal (arrow).he first 3 modes of failure of nonanatomic labral refixation are

llustrated here. (A, acetabulum.) (B) In LBR the labral base stitchnvolves a single passage of suture through the base of the labrumL). This achieves secure fixation of the labral base while preserv-ng the triangular cross-sectional anatomy of the labrum. Theontact of the labrum with the femoral head (FH) is preserved,llowing the labrum to serve its function as a suction seal and inegulating fluid ingress and egress from the joint. (A, acetabulum.)C) LBR with vertical mattress technique. The vertical mattressabral base stitch involves 2 passes of the suture through the basef the labrum (L). This technique is recommended when the widthf the labrum is at least 5 mm. In addition to providing securexation of the labral base, this technique is ideal in preserving the

IGURE 3. Labral repair with a simple stitch looped over theabrum in a left hip viewed from the anterolateral portal from theeripheral compartment. It should be noted that the repair achievespproximation of the labrum (L) to the acetabular rim but buncheshe labrum and disrupts the contact seal (arrows) with the femoralead (FH). This figure also shows the first 3 modes of failure ofonanatomic simple stitch repair.

riangular shape of the labrum and its fit against the femoral headFH). (A, acetabulum.)

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ortal Placement

The 2 portals that are routinely used are the antero-ateral and midanterior portals, as described by Kellyt al.26 These portals allow access to the majority ofhe acetabular rim and labrum, enabling treatment ofhe areas of common labral pathology and pincermpingement. These 2 portals also provide optimalngles for anchor placement on the acetabular rimetween 12 and 5 o’clock in the anterosuperior andnteroinferior quadrants. When rim trimming and la-ral detachment are carried out in the posterosuperioruadrant, a posterolateral portal as described byyrd38 is used for rim trimming and anchor place-ent.

cetabuloplasty With Labral Preservation

The LBR technique involves anatomic refixation ofhe labrum in cases of labral tears, usually in theetting of FAI. In its early stages, FAI may cause

IGURE 4. Splitting or intrasubstance tearing of the labrum (L) bypenetrating instrument in a right hip viewed from the anterolat-

ral portal. The use of a larger penetrating instrument, as shownere, is likely to cause injury to the labrum by virtue of its largeriameter. To avoid such injury, a smaller-diameter penetratingevice is preferred. (FH, femoral head; A, acetabulum.)

TABLE 1. Modes by Which Nonanatomic Repairs MayFail to Restore Contact Seal of Labrum Around

Femoral Head

unching of labrum due to compression by looped stitch (Fig 2A)istortion of triangular cross-sectional anatomy (Fig 2A)version of labrum away from femoral head (Fig 2A)plitting or intrasubstance tearing of labrum by penetrating

sinstrument (Fig 3)

earing at the chondrolabral junction due to shearorces while sparing the tip of the labrum.39 In theseases the degenerative base can be debrided and reat-ached, leaving the free edge to provide contact withhe femoral head. However, labral refixation is mostommonly applicable in FAI surgery involving ace-abular rim trimming, or acetabuloplasty.

When the labrum is in adequate condition, it shoulde preserved during acetabuloplasty for subsequentefixation. Labral preservation during acetabuloplastyan be achieved in 2 ways:

1. For minimal trimming of the rim of less than 3mm, acetabuloplasty without labral detachmentmay be performed. The capsule is elevated offof the acetabular rim in the area of pincer im-pingement by use of electrocautery, and a high-speed 5.5-mm bur is used to trim the acetabularrim on the capsular side of the labrum.

2. For trimming of more than 3 mm of rim, ac-etabuloplasty with labral detachment is gener-ally performed. First, a minimal acetabuloplastyis performed on the capsular side, with resectionof the first 3 mm of bone from the acetabularrim. This enables improved access for subse-quent labral detachment with a beaver blade ortissue elevator, with preservation of a maximalamount of labral tissue (Fig 5). After completionof the labral detachment, the labrum is retractedaway from the rim by use of the arthroscope ora switching stick while the remainder of theacetabuloplasty is performed.

When the labrum is unstable after acetabuloplasty,abral refixation is indicated. Notably, the acetabulo-lasty creates a bleeding bed of bone to facilitateiological healing of the labrum to the acetabular rimfter labral refixation. A decision algorithm for labralreservation and refixation during acetabuloplasty is

TABLE 2. Technique Goals in LBR

void splitting or intrasubstance tearing of labrumecurely reattach base of labrum to acetabular rimestore continuity of transitional zone between labrum andadjacent cartilage

e-create triangular cross-sectional geometry of labrumestore suction seal by achieving contact between labrum andfemoral headse knotless suture technique to avoid potential articularabrasion

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uture Passage and Anchor Placement

The LBR technique makes use of a labral basetitch, which is passed by use of a Suture LassoArthrex, Naples, FL) to pierce the labrum, and a stiffonabsorbable suture is passed through its base (Fig). The narrow diameter of this instrument avoidsplitting or intrasubstance tearing of the labrum, 1 ofhe potential pitfalls of puncture of the labrum. Thengle of passage of this stitch is of vital importance inorrectly restoring the labral anatomy. A knotless.9-mm PushLock suture anchor (Arthrex) is used tox the suture to the acetabular rim (Fig 2B and Video[available at www.arthroscopyjournal.org]). When

he detached labrum is greater than 5 mm in thickness,he LBR is performed with a vertical mattress stitchechnique by passing the suture twice through theabral base to achieve optimal anatomic refixation (FigC). When the labrum is less than 3 mm in thickness,he LBR technique is not recommended because thehin labrum may not support the labral base stitchTable 3).

The anchors may be placed through the posterolat-ral portal for the posterosuperior quadrant, the an-erolateral portal for the anterosuperior quadrant be-ween 12 and 2 o’clock, or the midanterior portal

IGURE 5. Labral detachment during acetabuloplasty of a left hipiewed from the anterolateral portal in the central compartment.abral detachment is performed before acetabuloplasty so as toreserve the labrum (L) during the rim trimming. The beaver blades used to carefully elevate the labrum off of the acetabular rim (A),ith preservation of as much labral tissue as possible. The beaverlade is seen here cutting along the chondrolabral junction. Theabrum can then be retracted away from the pincer lesion ascetabuloplasty is performed. (FH, femoral head.)

etween 2 and 5 o’clock for the anterosuperior andFa

nteroinferior quadrants (Table 4). These clock-faceuidelines reflect a right hip in the supine position,here 12 o’clock is superolateral, 3 o’clock is directly

nterior, 6 o’clock is inferior at the transverse acetab-lar ligament, and 9 o’clock is directly posterior. Thisrocedure is repeated for as many anchors as neces-ary to achieve appropriate fixation of the entire de-ached portion of the labrum. Anchors are normallypaced 6 to 8 mm apart. The LBR technique re-createshe triangular cross-sectional shape of the labrum andvoids eversion of the labrum away from the joint.hen viewed from the articular side, the transitional

one between the labrum and acetabular cartilage isell restored (Fig 8A). After traction is released, theiew from the peripheral compartment confirms con-act between all parts of the labrum and the femoralead, allowing restoration of labral function (Fig 8B).

DISCUSSION

The acetabular labrum is a peripheral articular fi-rocartilage complex that adds depth to joint geometrynd increases articular contact.21 The labrum has beenhown to increase articulating surface by 22% and

IGURE 6. Decision algorithm for labral preservation duringcetabuloplasty.

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cetabular volume by 33%.40 The labrum consists ofn inner, articular-sided layer of fibrocartilage and aarger, outer layer of dense connective tissue orga-ized in circular collagen fibrils. This circular orien-ation forms a tension ring that is connected at thenterior and posterior horns through the transversecetabular ligament.41 It has been shown that underension, the labrum is actually 10 to 15 times stifferhan the articular cartilage.25

It is thought that when the joint is unloaded, syno-ial fluid is able to enter the joint to provide nutritionnd lubrication.42 The labrum, which possesses pro-rioceptive and nociceptive properties, guides theemoral head into the joint under compressive loadingy establishing joint contact at the periphery.21,43,44

hen peripheral contact is established first, the la-rum is able to seal the pressurized synovial fluid inhe joint because of its high resistance to radial inter-titial flow. The pressurized synovial fluid transmitshe load within the cartilage layers to the underlyingubchondral bone and slows the expression of fluid

IGURE 7. Labral base stitch in a right hip viewed from thenterolateral portal. The stitch is passed through the labrum (L)ith the Suture Lasso. In this case a No. 2 FiberStick suture

Arthrex) is passed directly through the penetrating instrument,ypassing the need for the Suture Lasso to pass suture. The correctngle of passage of the suture is critical to restoring the anatomy ofhe labrum. (FH, femoral head; A, acetabulum.)

TABLE 3. Selection of Labral Stitch Technique

Thickness of Labrum Preferred Refixation Technique

�5 mm LBR with vertical mattress technique3-5 mm LBR with single-pass technique

b�3 mm Looped simple stitch technique

ut of the cartilage matrix, reducing the solid contacttresses on the cartilage.22,24,25 The egress of synovialuid out of the cartilage matrix under compression isnown as consolidation. Ferguson et al.24 showed thatabral excision in a cadaveric model increased the ratef consolidation by 22%. This rate increased to 48%n joints identified as having a closer fit between theabrum and femoral head. A poroelastic finite elementodel showed a 40% increase in consolidation rateith labral excision.23 It was emphasized in this study

hat the function of the labrum in this capacity isependent on the contact between the labrum and theemoral head.

Loss of the labral seal has also been shown toestabilize the hip in a cadaveric model.45 Femoralead motion increased with both venting of the cap-ule and creation of a labral tear. Venting of theapsule and subsequent labral injury caused 43% and0% decreases, respectively, in traction required toreate 3 mm of joint distraction. This shows that bothhe capsular integrity and labral integrity contribute tohe vacuum seal of the joint.

The junction of the labral base and the articularurface of the acetabular rim may be important. Find-ngs from revision arthroscopies have shown that theoint capsule can adhere both to the vascularized cap-ular side of the labrum and to the site of previouscetabuloplasty.46,47 Similarly, acetabular labral heal-ng in a sheep model shows 2 types of labral healing,brovascular ingrowth from the peripheral joint cap-ule and direct healing of the labrum to acetabular rimhrough new bone formation, likely endochondral os-ification of fibrous attachment.35 Espinosa et al.15

mphasized the importance of this bony healing andhe need to prepare a bleeding cancellous acetabularim because of the avascularity of the inner two-thirdsf the labrum.A limitation of this technique is that certain patientsay have labra that are too thin to support a labral

TABLE 4. Portal Selection for Anchor Placement

Anchor Placement Portal

osterosuperior: 10-12 o’clock Posterolateralnterosuperior: 12-2 o’clock Anterolateralnteroinferior: 2-5 o’clock Midanterior

NOTE. These clock-face guidelines reflect a right hip in theupine position, where 12 o’clock is superolateral, 3 o’clock isirectly anterior, 6 o’clock is inferior at the transverse acetabularigament, and 9 o’clock is directly posterior.

ase stitch. For this reason, the LBR technique is not

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ecommended if the labrum is thinner than 3 mm.nother concern with this technique, as with many

rthroscopic hip procedures, is the necessity for partialapsulotomy. Although LBR preserves the anatomyf the labrum, the function of which has beenhown to slow cartilage consolidation, the capsulot-my has also been found to affect cartilage consol-dation.24 Whether the capsulotomy and its effects on

IGURE 8. (A) Completed LBR in a right hip viewed from thenterolateral portal. This intra-articular view from the central com-artment shows the restoration of the normal anatomy of theabrum (L). The nearly seamless transition between the articularartilage and labrum at the chondrolabral junction (arrow) shoulde noted. (FH, femoral head; A, acetabulum.) (B) Completed LBRn a left hip viewed through the anterolateral portal from theeripheral compartment after release of traction. It should be notedhat the tight contact (arrows) between the labrum (L) and femoralead (FH) has been restored throughout the area of labral repair.he restoration of contact with the femoral head reproduces the

babral seal. This allows the labrum to function in maintenance ofuid flow, stability, and suction seal. (A, acetabulum.)

artilage consolidation have long-term clinical impli-ations is yet to be determined. Furthermore, althoughhort-term follow-up has shown improved outcomesith labral repair versus labral debridement, long-

erm results are needed to determine whether the nat-ral history of FAI has been affected. Biomechanicalnd clinical studies will also be essential to determinehether LBR has significant advantages over simple

abral repair.

CONCLUSIONS

The 6 goals of labral refixation are directed atestoring the functional anatomy of the labrum. TheBR technique was designed to achieve these goals

Table 5). Splitting and intrasubstance tearing arevoided by use of a small-diameter suture shuttle toass the labral base stitch through the labrum. Secureeattachment is accomplished with a sufficient numberf labral base stitches and anchors, spaced 6 to 8 mmpart. The correct angle of passage of each labral basetitch ensures that the labrum will be fixed to thecetabular rim in an anatomic position, restoring theransitional zone by close approximation of the labralase to the articular cartilage. Triangular cross-sec-ional geometry of the labrum is preserved by theabral base stitch configuration, which does not bunchr crush the labrum but rather leaves the labral edgeree. The LBR avoids eversion of the labrum andtrives to reproduce the suction seal by restoring con-act with the femoral head. Finally, the refixation iserformed with a knotless technique, avoiding anyotential abrasion of the articular cartilage by knots.Restoration of anatomy is a principle that is increas-

ngly considered of paramount importance throughouthe field of arthroscopy. The LBR technique followshis principle by providing an anatomic approach toabral repair. This may restore labral function afterrthroscopic refixation by allowing the labrum toerve its functions in fluid regulation, stability, load

TABLE 5. Technique Pearls for LBR

se disposable cannula for working portal.se low-profile penetrating device to pass suture through labralbase.chieve correct passage angle to approximate labral base toacetabular rim.

lace anchors as close to articular surface as possible.atch articular surface during anchor placement to avoidarticular penetration.

earing, and maintenance of the suction seal.

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Labral Base Refixation in the Hip: Rationale and Technique for an Anatomic Approach to Labral RepairRATIONALE FOR ANATOMIC LABRAL REPAIRCURRENT LABRAL REPAIR TECHNIQUESSURGICAL TECHNIQUE: LABRAL BASE REFIXATIONPortal PlacementAcetabuloplasty With Labral PreservationSuture Passage and Anchor Placement

DISCUSSIONCONCLUSIONSREFERENCES