What did the study look at?
The labrum is a ring of tissue around the rim of the hip socket. The authors explain that it helps protect the cartilage by maintaining joint fluid and pressure, and that it contributes to the hip's resistance to being pulled apart by creating a suction seal around the femoral head.
In cam-type impingement (a bony bump on the femoral neck), bone is removed arthroscopically. The authors note that incomplete removal is the leading cause of failed hip arthroscopy, whereas removing too much bone can disrupt the fit between the femoral head and the labrum and cause loss of the suction seal. The paper describes the technique used in a patient with both problems.
How was it done?
This is a surgical technique paper (Technical Note) describing a single left hip revision with video and images. Patient outcomes were not measured.
- Before surgery: in a patient with persistent or recurrent pain after previous arthroscopy, a lateral hip X-ray, CT and 3D CT showed over-resection at the front of the femoral head-neck junction.
- Labral reconstruction: as the labrum was too degenerate to repair, the defect was measured and a semitendinosus tendon allograft 5–6 mm wide and about 30% longer than the defect was prepared. It was pulled into place and fixed with suture anchors on the socket rim using the "kite technique".
- Remplissage: after traction was released, a dynamic hip examination during surgery identified where the suction seal was lost. A second graft made from the remainder of the same allograft was fixed there with anchors with the hip at 20–30° of flexion, and a third anchor tensioned the graft at its mid-portion.
- Finally, the dynamic examination was repeated to check graft position and whether the seal had been restored, and the capsule was closed.
What did it find?
The authors report that, in this case, intraoperative dynamic hip examination confirmed restoration of the suction seal. The advantages they list are:
- The suction seal can be re-established with labral reconstruction and remplissage guided by dynamic examination.
- Both procedures can be done in the same session with one allograft.
- With the kite technique, graft tension and position can be checked arthroscopically before any suture is tied.
Pitfalls are also noted: a graft that is too thick at the femoral neck may cause cam-type impingement symptoms, and placing a graft in the wrong area or with insufficient thickness without dynamic examination may prevent the seal from being restored.
The authors' conclusion
The authors state that loss of the suction seal warrants treatment because it can impair cartilage lubrication and nutrition and accelerate cartilage degeneration. The technique offers an option to restore the seal in a patient with an irreparable labrum and a previously over-resected cam lesion. They advise surgeons early in their learning curve to pay particular attention to its pearls and limitations.
Limitations
- Combining two advanced procedures in one session may be technically difficult in hip arthroscopy, which has a long learning curve.
- Operating time may be longer than a standard arthroscopy with labral repair and cam resection.
- Where over-resection is very severe, filling with soft tissue may not be enough.
- Poor management of time under traction may cause traction-related risks.
Reference
Gürsoy S, Vadhera AS, Singh H, Perry AK, Nho SJ, Chahla J. 2021. Remplissage and Labral Reconstruction Technique Correlated With Dynamic Hip Examination Using the Kite Technique for Restoration of the Suction Seal in Revision Hip Arthroscopy. Arthroscopy Techniques. 10(8):e1995–e2004. Licence: CC BY-NC-ND 4.0.
DOI: 10.1016/j.eats.2021.04.027
Free full text: PubMed Central PMC8355511
This article summarises a published scientific paper for general information; it does not replace an examination or a personal medical assessment. Please consult your doctor about your symptoms.
