Arthroscopic Hip Labral Reconstruction With Fresh Meniscal Allograft

Figures

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  Fig 1. Arthroscopic drill guide (G) is placed at the posterior extent of the prepared acetabulum (A). Note the remnant posterior labrum (La). Medial (M), lateral (L). Left hip viewed with 70° arthroscope from modified mid anterior portal.

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  Fig 7. (A) Meniscal allograft (MG) labral reconstruction in place along the acetabular rim prior to final tensioning. (B) After final tensioning. Medial (M), lateral (L). Left hip viewed with 70° arthroscope.

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  Fig 2. The “junctional repair stitch” is passed through the remnant posterior labrum (L). Note the prepared acetabular rim (R) for allograft fixation. Medial (M), lateral (L). Left hip viewed with 70° arthroscope from modified mid anterior portal.

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  Fig 3. The suture (S) from the anterior-most anchor (AA) is manipulated across the prepared acetabular rim (R), to the posterior-most anchor (PA), with a knot pusher to measure the defect. Medial (M), lateral (L). Left hip viewed with 70° arthroscope from anterolateral portal.

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  Fig 4. Two hemostat clamps are used to determine the length of the suture that traverses the acetabular rim as shown in Fig 3. The first hemostat (1) is placed with the knot pusher flush against the suture at the anterior anchor, while the second that is placed on the knot pusher brings the suture to the posterior anchor (2). Distance is then obtained, and 7 mm is added. Right hip is used here for demonstration purposes, and the camera is in anterolateral portal in this image. Sutures are out of the distal anterolateral portal.

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  Fig 5. A suture limb from the anterior most anchor (AS), and posterior most anchor (PS), are retrieved via the distal anterolateral portal to shuttle the graft into the joint. Care needs to be taken to ensure the PS limb is anterior to the already passed suture limb in the native labrum (LS). Medial (M), lateral (L). Left hip viewed with 70° arthroscope from anterolateral portal.

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  Fig 6. Using the arthroscopic measurement for length, the surgeon marks the meniscus allograft for sharp trimming to final size and shape by mapping the required dimensions on its femoral surface, such that the peripheral curvature is minimized, and the thickness and width match the native labrum. FiberLink passing sutures of alternating colors are placed in the graft from the anterior-most aspect of the graft (1) to the posterior most (4) with (5) corresponding to the site for the junctional suture. Numbered hemostats are applied for suture management purposes.

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  Fig 10. Summary of our surgical technique. (A) The portals used for arthroscopic labral reconstruction include the anterior lateral (AL), modified midanterior portal (MMAP), proximal accessory portal (AP), and distal anterolateral accessory portal (DALA). (B) The graft is shuttled via the DALA portal via a suture limb from the anterior-most (#1) and posterior-most (#5) anchor. (C) The graft is prepared for corresponding anchor placement. Passing sutures are placed (#1-4), and the passing limb from the posterior anchor #5, is passed with a free needle, and a mulberry knot is tied for suture shuttling. (D) Graft is seated, and sequential passing of the subsequent anchors occurs. Passing stitch #2 is retrieved via the DALA. (E) Sequential fixation occurs, here the passing stitch #3 is in the DALA portal, as well as the repair stitch from anchor #3. Note that the previously passed repair stitch from anchors #1 and #2 is in the MMAP, and the passing suture #4 is in the AP. (F) Final construct after sequential tightening.

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  Fig 8. Junctional stitch (#5) being tied to connect the meniscal labral allograft (MG) with the remnant native labrum (L). Medial (M), lateral (L). Left hip viewed with 70° arthroscope from anterolateral portal.

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  Fig 9. Final meniscal allograft (MG) labral reconstruction after final tensioning and placement of junctional stitch. Medial (M), lateral (L). Left hip viewed with 70° arthroscope from anterolateral portal.