Patients are placed in the supine position and traction is placed with the operative hip. Standard arthroscopic portals are established as has been described in a previous chapter.

A diagnostic arthroscopy is performed and an interportal capsulotomy is routinely performed. The labrum is examined to determine if a labral reconstruction is necessary. The quality and stability of the remaining labral tissue are examined. A dynamic examination is performed to assess the suction seal between the injured labrum and the femoral head. The damaged section of the labrum is identified and removed with shavers, leaving healthy tissue at each end. The healthy labral tissue is needed at each end in order to attach the labral graft to the native labrum. After removal of the labral tissue, rim trimming and treatment of the articular cartilage during labral reconstruction are facilitated for improved visualization.

The autograft tissue currently used is the iliotibial band (ITB). The traction is released, and the graft is harvested with the leg in extension through a longitudinal incision centered over the greater trochanter, just distal to the anterolateral portal. At the junction of the anterior 2/3 and posterior 1/3 of the ITB, a rectangular piece of tissue 15–20 mm wide and 30–40 % longer than the measured defect is used. The ITB defect is not closed if there is no significant herniation of muscle or if excessive tension in the ITB occurs with attempted closure. The graft is cleaned of any soft tissue. At each end, #2 Vicryl sutures are placed and tied with locking knots. The graft is tubularized with 2-0 Vicryl. The thicker end of the graft gets a loop suture which will facilitate intra-articular maneuverability.

For placement of the graft, a suture anchor is placed at the most anterior aspect of the defect. One limb of the suture is passed through the graft extracorporeally, and the knot is pushed to introduce the graft to the joint via the mid-anterior portal through a 5.5 mm cannula (Fig. 13.2). The second suture limb is used for a side to side anastomosis with the healthy tissue at each end of the defect. A suture anchor is then placed at the posterior aspect of the defect and the graft is secured. Suture anchors are then placed along the graft to ensure stability of the graft (Fig. 13.3a). Combinations of two types of suture anchors are used to restore the seal. The loop suture, which goes around the graft tissue, tends to evert the labrum (Fig. 13.3b). The pierced suture, which goes through the graft tissue, tends to invert the labrum tissue (Fig. 13.3c). Using a combination of these sutures to manage the position of the graft results in better restoration of the suction seal. Sutures are placed until the autograft is stable. If the graft is unstable at certain positions, then additional sutures are added. Traction is released and a dynamic exam is performed to ensure the suction seal has been restored. The dynamic examination should include moving the hip through full range of motion to ensure adequate seal (Fig. 13.4). If the graft appears unstable, additional suture anchors can be placed. In addition, any cam or pincer impingement that may further damage the new graft can be identified and resected during the hip arthroscopy examination. If necessary, further burring of the femoral neck can be performed at this time. The graft should resemble the native labrum and should recreate the suction seal of the hip joint. A flexible radiofrequency device can now be used to make the graft and the native labrum smooth by removing frayed edges to ensure good visualization.

Postoperative rehabilitation protocols are the same for labral repair and labral reconstruction. Patients ride a stationary bike with no resistance within 4 h after surgery and use a continuous passive motion (CPM) machine immediately following surgery until 2–3 weeks postoperatively. They are kept at 9 kg of flat foot weight bearing for 2–3 weeks as well. This time is increased to 8 weeks if a microfracture procedure was performed. Patients are advised to wear an anti-rotational bolster and a hip brace to prevent stress on the repaired capsule. The goal of rehabilitation in the first 2–3 weeks is to prevent adhesions, especially in those patients with prior adhesions, and protect the repair. Early rehabilitation will help the patient regain pain-free motion while protecting the new labral graft. Of note, other graft choices include autograft (gracilis tendon) and allograft (gracilis tendon, tibialis tendon).

Since the description of the labral reconstruction techniques, there have been numerous studies describing the technique and clinical outcomes [1–5, 26–29]. A systematic review by Ayeni et al. reviewed the literature on FAI and labral reconstruction [26]. The review included 5 studies and 128 patients. The authors documented improvement in outcomes and a conversion rate to total hip arthroplasty of 20 %. This systematic review concluded that labral reconstruction is a new technique that shows short-term improvement in terms of symptoms and function.

A cohort study by Domb et al. compared 11 reconstructions to 22 resections [29]. The reconstruction group was younger and showed greater improvement for all outcome scores. Similar findings were reported in another cohort study comparing 8 reconstructions to 46 labral refixations [2]. The reconstruction group showed greater improvement. However, the reconstruction group was older. In a large case series, Geyer et al. reported significant improvement in average modified Harris Hip score, HOS-ADL, and HOS sport score in 77 patients who underwent labral reconstructions [1]. Conversion to total hip arthroplasty was documented in 23 % of the patients, and these patients were older at time of reconstruction. In addition, limited joint space (2 mm or less) was a predictor of conversion to arthroplasty. At 3 years, 46 % of patients with 2 mm or less joint space survived with no joint replacement. This study emphasized the need for proper patient selection to achieve good results.

Labral reconstruction has also been shown to be effective in returning the elite athlete to the playing field. In a study by Boykin et al., 89 % of top-level athletes returned to play following labral reconstruction [27].

In addition to clinical studies, several biomechanics studies have also shown that labral reconstruction can improve the hip environment. In a study by Lee et al., labral resection decreased contact area, and labral reconstruction partially restored acetabular contact areas and pressures [30].

The hip capsule consists of the iliofemoral ligament, the ilioischial ligament, the pubofemoral ligament, and the zona orbicularis. These ligaments that make up the capsule complex provide a critical component for maintaining stability in the hip. While the hip is considered a relatively stable joint due to the seating of the femoral head in the acetabulum, and vast soft tissue envelope, injuries to the hip capsule may result in hip instability [31]. Although traumatic injuries to the hip, such as dislocation, may be rare, chronic or repetitive injuries occur in activities or sports that require rotation around the hip. In addition, management of capsulotomies during hip arthroscopy have varied, including leaving the capsulotomy open. This has led to cases of deficient capsules that no longer provide the needed stability in certain cases [22]. A study by Bayne et al. demonstrated that following capsulotomy there was increased translation and rotation of the femoral head [32]. Indication for capsular reconstruction includes patient-reported instability, pain, and deficient capsule on radiographic and arthroscopic evaluation [6].

For many years, the ligamentum teres (LT) was viewed as a vestigial structure in the adult. There has been a growing body of literature that suggests the ligamentum teres plays an important role in hip biomechanics [33–38]. A study by Wenger et al. on porcine models demonstrated LT possesses tensile strength similar to ACL [38]. Recently in a cadaveric study by Kivlan et al., it was shown that the LT formed a “sling-like” structure to support the femoral head inferiorly as the hip joint was moved into squat position [34]. The LT appeared to prevent anterior/inferior subluxation of femoral head. The LT is tightest when the hip is flexed, adducted, and externally rotated [34].