Arthroscopic Labral Repair of the Hip, Using a Through-Labral Double-Stranded Single-Pass Suture Technique Ken Ye, M.B.B.S., B.Med.Sci., and Parminder J. Singh, M.B.B.S., M.R.C.S., F.R.C.S.(Tr&Orth), M.S., F.R.A.C.S.
Abstract: The normal labrum is crucial to the biomechanical function of the hip joint, not only increasing the surface area and depth of the acetabulum but also maintaining a suction seal to assist in normal synovial fluid flow from the peripheral to the central compartment. Simple loop suture repairs of the labrum may evert the labrum, thus losing the optimal seal, as well as causing abrasion of the articular cartilage. Vertical mattress suture and labral base fixation techniques aim to leave the free edge of the labrum intact and undisturbed, therefore improving the contact of the labrum to the femoral head and neck to improve the seal of the acetabulum. We aim to describe a double-stranded single-pass vertical mattress suture technique that may allow greater versatility to the surgeon in repairing thinner labrums while still achieving a free and continuous free edge.
T
he integrity of the acetabular labrum is crucial to the normal biomechanical function of the hip joint. One of the properties of the labrum includes increasing the surface area and depth of the acetabulum to improve joint stability and the distribution of biomechanical force for weight bearing. Another function of the labrum is to maintain a suction seal to assist in normal flow of synovial fluid from the peripheral to the central compartment.1-3 Labral damage resulting in a loss of seal and abnormal fluid biomechanics can potentially lead to accelerated cartilage wear and increased load-bearing stresses of the joint.2-4 The labrum is particularly vulnerable to injury in the presence of femoroacetabular impingement (FAI). Several studies have shown significantly improved outcomes after labral repair compared with labral resection.5,6
From Bellbird Private Hospital (K.Y.); Maroondah Hospital (P.J.S.); Eastern Health (P.J.S.); Monash & Deakin University (P.J.S.); St. Vincent’s Private Hospital East Melbourne (P.J.S.); and Hip Arthroscopy Australia (P.J.S.), Melbourne, Australia. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received April 23, 2014; accepted July 10, 2014. Address correspondence to Parminder J. Singh, M.B.B.S., M.R.C.S., F.R.C.S.(Tr&Orth), M.S., F.R.A.C.S., 21 Erin Street, Richmond VIC 3121, Australia. E-mail: [email protected] Ó 2014 by the Arthroscopy Association of North America 2212-6287/14341/$36.00 http://dx.doi.org/10.1016/j.eats.2014.07.003
A number of labral repair techniques have been described, although strong scientific evidence favoring any particular technique is lacking.7-9 Domb and Botser10 compared labral preservation techniques of labral base refixation, simple loop refixation, and selective partial debridement in a prospective study of 230 patients. They found no significant differences in shortterm clinical outcomes among the 3 techniques. However, the 3 groups were not matched for intraoperative pathology or patient characteristics. The study recommended that the type of labral tear and clinical context should dictate the appropriate choice of labral repair technique. Evidently, the technique of simple loop repair versus through-labral repair remains contentious. Currently, most surgeons use sutures to repair the labrum and anchors to secure the sutures to the acetabular bone. Until recently, sutures were looped over the labrum. Although the labrum repair was secure
Table 1. Distraction Force of Hip Fluid Seal in Labral Repair in Cadaveric Study by Nepple et al.13 Maximal Distraction Force as % of Normal Intact Labrum Labral tear Partial resection Looped repair Through repair
76 34 29 26 Median, 72 (minimum, 54; maximum, 102) Median, 92 (minimum, 79; maximum, 105)
NOTE. Data are summarized from Nepple et al.13 and are presented as mean SD unless otherwise indicated.
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Fig 1. Labral repair technique and path of suture. The looped suture is passed through the mid labrum (step 1) and through the chondrolabral junction (step 2), creating a double suture loop over the proximal half of the labrum. The suture ends are passed through the loop (step 3) and attached to the anchor (step 4). The anchor is placed securely into the acetabulum, which has been debrided and predrilled (step 5). During this process, the anchor is tensioned to restore the anatomy of the labral tear. (A, acetabulum; FH, femoral head; L, labrum.)
using this technique, there were 2 potential issues that could be avoided using an alternative technique. One issue comprised labral eversion using the over-the-top technique and therefore disrupting the vacuum-seal effect of the socket; the second issue was the suture causing abrasion of the articular cartilage.3,11,12 More recently, techniques such as vertical mattress sutures passed through the labrum and labral base fixation have
been used to address these problems.9,11,12 In theory, the free edge of the labrum is left undisturbed and fixation of the labrum to the acetabulum occurs closer to the base of the labrum, thus improving the contact of the labrum to the femoral head and neck to improve the seal of the socket and reduce suture contact with the articular cartilage. A recent cadaveric study showed significantly improved fluid pressurization using the
ARTHROSCOPIC DOUBLE-STRANDED LABRAL REPAIR
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Fig 2. Arthroscopic images of labral repair technique. Intraoperative images show, in this instance, (A) labral detachment using a labral knife, (B, C) followed by passing the looped suture through the labrum at approximately halfway through the labrum. (D) The loop is taken back through the chondrolabral junction, externally looped around the suture end, and attached to the anchor (not shown). (E) The anchor is passed down to the subchondral acetabulum adjacent to the labral tear and securely fastened to the subchondral bone. (F) The result is a double suture loop through the labrum and secured to an anchor in the subchondral bone, leaving the free edge of the labrum intact, continuous, and not everted. (A, acetabulum; Anc, anchor; C, capsule; FH, femoral head; L, labrum.)
through-type labral suture repair compared with a looped-type repair.13 The authors showed significant improvement in the hip fluid seal of through-labral repairs versus loop labral repairs. Table 1 summarizes the distraction force required to overcome the resistance of the hip fluid seal after repair of labral tears using looped- and through-type repairs based on the cadaveric study of Nepple et al.13 We aim to describe a
double-stranded single-pass vertical mattress suture technique for labral repair.
Surgical Technique We use the lateral approach to the hip as previously described.14 In brief, the patient is placed in the lateral decubitus position and the affected hip in traction. Two portals are used for access: the proximal trochanteric
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K. YE AND P. J. SINGH Table 2. Advantages and Limitations of Through-Labral Double-Stranded Single-Pass Suture Technique for Arthroscopic Labral Repair Advantages Double suture gives added strength to repair Maintenance of continuous labral free edge to improve labral seal Avoids eversion of labral edge after repair Knotless anchor Limitations Limited use in thin labrums Limited use in labral tears in which free edge is already compromised Non-dissolvable suture
Fig 3. Arthroscopic image of labral repair after femoral head (FH) is engaged in socket. This image, taken during dynamic testing after cam resection, shows the free edge of the labrum forming a complete seal against the femoral head. The vertical arrows show the labrum gliding over the femoral head. The cut suture ends can be seen in the background as indicated by the diagonal arrow showing the repair.
portal and the anterior paratrochanteric portal. A diagnostic arthroscopy is performed to confirm the presence of a labral tear or associated pathologies within the central compartment. An intraportal capsulotomy is performed to gain adequate exposure of the hip joint. In the presence of a labral tear, the acetabular bone adjacent to the labral tear is cleared of soft tissue and a high-speed burr (5.5-mm Dyonics Elite Abrader Burr; Smith & Nephew, London, England) is used to provide a fresh bleeding bony bed for fixation of the labral anchor. Through the anterior portal, the suture loop (FiberLink; Arthrex, Naples, FL) is passed through the midsubstance of the labrum using a sharp suture-passing device (Nanopasser Crescent; Pivot Medical, Sunnyvale, CA). The advantage of using a needle penetratoretype device is that it is less traumatic to the labrum than a bird-beak device. The same device is then passed through the chondrolabral junction to retrieve the suture loop and is brought out of the anterior portal. The loop allows 2 strands to encircle the base of the labrum. Once out of the anterior portal, the free ends of the suture are passed through the loop to create a knot. The acetabulum is then prepared and drilled for anchor placement. The location for anchor placement should be in the subchondral bone close to the articular surface without penetrating the acetabular cartilage. The free ends of the suture are then attached to a knotless anchor and should pass freely
through the anchor to allow tensioning. We use the 2.9mm Quattro Link Knotless Anchor (Cayenne Medical, Scottsdale, AZ). The anchor is placed in the acetabulum and tensioned to restore labral anatomy (Figs 1 and 2). This technique allows the free edge of the labrum to remain continuous and re-establish the suction seal of the labrum. During dynamic testing, the seal can be tested (Fig 3). The entire surgical technique is shown in Video 1, including audio narration.
Discussion The best method for labral repair remains to be proved. Current evidence does not provide a clear, definitive answer and indeed may be difficult to measure. However, if the goal of labral repair is to restore the anatomy and re-establish a seal around the femoral head and neck, leaving the free margin of the labrum intact and continuous without eversion, our technique theoretically achieves this goal. We argue that using a through-labral repair technique may have an advantage over loop suture techniques in achieving these goals. With all labral repairs, it is important to recognize, diagnose, and treat the underlying pathologic process, whether it is cam impingement, pincer impingement, dysplasia, or hyperlaxity. One limitation of all vertical mattressetype sutures is the thickness of the labrum and, therefore, whether using only a portion of the labrum for suture fixation is sufficient, particularly in a degenerative labrum. In our technique, by passing a loop through the labrum, we effectively create a double suture loop at the point of fixation, and this may be an advantage over a single loop in a thin or degenerative labrum. Another advantage of this technique is the use of a knotless anchor system that allows greater manipulation of the tension of the anchor suture. Both over- and undertensioning of the labrum could result in suboptimal restoration of labral anatomy and function. Like other vertical mattress suture techniques, this technique is limited to cases in which the continuous labral free edge is maintained. Table 2 highlights the advantages and limitations of this technique. We argue that arthroscopic
ARTHROSCOPIC DOUBLE-STRANDED LABRAL REPAIR
labral repair of the hip, using a through-labral doublestranded single-pass suture technique with a vertical mattress technique, allows greater versatility to the surgeon in repairing thinner labrums while still achieving a free and continuous free edge.
7.
8.
References 1. Seldes RM, Tan V, Hunt J, Katz M, Winiarsky R, Fitzgerald RH Jr. Anatomy, histologic features, and vascularity of the adult acetabular labrum. Clin Orthop Relat Res 2001;(382):232-240. 2. Ferguson SJ, Bryant JT, Ganz R, Ito K. The acetabular labrum seal: A poroelastic finite element model. Clin Biomech 2000;15:463-468. 3. Ferguson SJ, Bryant JT, Ganz R, Ito K. An in vitro investigation of the acetabular labral seal in hip joint mechanics. J Biomech 2003;36:171-178. 4. Greaves LL, Gilbart MK, Yung AC, Kozlowski P, Wilson DR. Effect of acetabular labral tears, repair and resection on hip cartilage strain: A 7T MR study. J Biomech 2010;43:858-863. 5. Espinosa N, Rothenfluh DA, Beck M, Ganz R, Leunig M. Treatment of femoro-acetabular impingement: Preliminary results of labral refixation. J Bone Joint Surg Am 2006;88:925-935. 6. Krych AJ, Thompson M, Knutson Z, Scoon J, Coleman SH. Arthroscopic labral repair versus selective labral debridement in female patients with femo-
9.
10.
11.
12.
13.
14.
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roacetabular impingement: A prospective randomized study. Arthroscopy 2013;29:46-53. Kelly BT, Weiland DE, Schenker ML, Philippon MJ. Arthroscopic labral repair in the hip: Surgical technique and review of the literature. Arthroscopy 2005;21:1496-1504. Murphy KP, Ross AE, Javernick MA, Lehman RA Jr. Repair of the adult acetabular labrum. Arthroscopy 2006;22:567.e1-567.e3. Available at www. arthroscopyjournal.org. Freehill MT, Safran MR. The labrum of the hip: Diagnosis and rationale for surgical correction. Clin Sports Med 2011;30:293-315. Domb BG, Botser IB. Paper 30: Clinical results of arthroscopic treatment of acetabular labral tears using three methods. Arthroscopy 2012;28:e60-e61 (abstr, suppl 2). Larson CM, Giveans MR. Arthroscopic management of femoroacetabular impingement: Early outcomes measures. Arthroscopy 2008;24:540-546. Fry R, Domb B. Labral base refixation in the hip: Rationale and technique for an anatomic approach to labral repair. Arthroscopy 2010;26:S81-S89 (suppl). Nepple JJ, Philippon MJ, Campbell KJ, et al. The hip fluid sealdPart II: The effect of an acetabular labral tear, repair, resection, and reconstruction of hip stability to distraction. Knee Surg Sports Traumatol Arthrosc 2014;22:730-736. Mason JB, McCarthy JC, O’Donnell J, et al. Hip arthroscopy: Surgical approach, positioning, and distraction. Clin Orthop Relat Res 2003;406:29-37.
Abstract: The normal labrum is crucial to the biomechanical function of the hip joint, not only increasing the surface area and depth of the acetabulum but also maintaining a suction seal to assist in normal synovial fluid flow from the peripheral to the central compartment. Simple loop suture repairs of the labrum may evert the labrum, thus losing the optimal seal, as well as causing abrasion of the articular cartilage. Vertical mattress suture and labral base fixation techniques aim to leave the free edge of the labrum intact and undisturbed, therefore improving the contact of the labrum to the femoral head and neck to improve the seal of the acetabulum. We aim to describe a double-stranded single-pass vertical mattress suture technique that may allow greater versatility to the surgeon in repairing thinner labrums while still achieving a free and continuous free edge.
T
he integrity of the acetabular labrum is crucial to the normal biomechanical function of the hip joint. One of the properties of the labrum includes increasing the surface area and depth of the acetabulum to improve joint stability and the distribution of biomechanical force for weight bearing. Another function of the labrum is to maintain a suction seal to assist in normal flow of synovial fluid from the peripheral to the central compartment.1-3 Labral damage resulting in a loss of seal and abnormal fluid biomechanics can potentially lead to accelerated cartilage wear and increased load-bearing stresses of the joint.2-4 The labrum is particularly vulnerable to injury in the presence of femoroacetabular impingement (FAI). Several studies have shown significantly improved outcomes after labral repair compared with labral resection.5,6
From Bellbird Private Hospital (K.Y.); Maroondah Hospital (P.J.S.); Eastern Health (P.J.S.); Monash & Deakin University (P.J.S.); St. Vincent’s Private Hospital East Melbourne (P.J.S.); and Hip Arthroscopy Australia (P.J.S.), Melbourne, Australia. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received April 23, 2014; accepted July 10, 2014. Address correspondence to Parminder J. Singh, M.B.B.S., M.R.C.S., F.R.C.S.(Tr&Orth), M.S., F.R.A.C.S., 21 Erin Street, Richmond VIC 3121, Australia. E-mail: [email protected] Ó 2014 by the Arthroscopy Association of North America 2212-6287/14341/$36.00 http://dx.doi.org/10.1016/j.eats.2014.07.003
A number of labral repair techniques have been described, although strong scientific evidence favoring any particular technique is lacking.7-9 Domb and Botser10 compared labral preservation techniques of labral base refixation, simple loop refixation, and selective partial debridement in a prospective study of 230 patients. They found no significant differences in shortterm clinical outcomes among the 3 techniques. However, the 3 groups were not matched for intraoperative pathology or patient characteristics. The study recommended that the type of labral tear and clinical context should dictate the appropriate choice of labral repair technique. Evidently, the technique of simple loop repair versus through-labral repair remains contentious. Currently, most surgeons use sutures to repair the labrum and anchors to secure the sutures to the acetabular bone. Until recently, sutures were looped over the labrum. Although the labrum repair was secure
Table 1. Distraction Force of Hip Fluid Seal in Labral Repair in Cadaveric Study by Nepple et al.13 Maximal Distraction Force as % of Normal Intact Labrum Labral tear Partial resection Looped repair Through repair
76 34 29 26 Median, 72 (minimum, 54; maximum, 102) Median, 92 (minimum, 79; maximum, 105)
NOTE. Data are summarized from Nepple et al.13 and are presented as mean SD unless otherwise indicated.
Arthroscopy Techniques, Vol 3, No 5 (October), 2014: pp e615-e619
e615
e616
K. YE AND P. J. SINGH
Fig 1. Labral repair technique and path of suture. The looped suture is passed through the mid labrum (step 1) and through the chondrolabral junction (step 2), creating a double suture loop over the proximal half of the labrum. The suture ends are passed through the loop (step 3) and attached to the anchor (step 4). The anchor is placed securely into the acetabulum, which has been debrided and predrilled (step 5). During this process, the anchor is tensioned to restore the anatomy of the labral tear. (A, acetabulum; FH, femoral head; L, labrum.)
using this technique, there were 2 potential issues that could be avoided using an alternative technique. One issue comprised labral eversion using the over-the-top technique and therefore disrupting the vacuum-seal effect of the socket; the second issue was the suture causing abrasion of the articular cartilage.3,11,12 More recently, techniques such as vertical mattress sutures passed through the labrum and labral base fixation have
been used to address these problems.9,11,12 In theory, the free edge of the labrum is left undisturbed and fixation of the labrum to the acetabulum occurs closer to the base of the labrum, thus improving the contact of the labrum to the femoral head and neck to improve the seal of the socket and reduce suture contact with the articular cartilage. A recent cadaveric study showed significantly improved fluid pressurization using the
ARTHROSCOPIC DOUBLE-STRANDED LABRAL REPAIR
e617
Fig 2. Arthroscopic images of labral repair technique. Intraoperative images show, in this instance, (A) labral detachment using a labral knife, (B, C) followed by passing the looped suture through the labrum at approximately halfway through the labrum. (D) The loop is taken back through the chondrolabral junction, externally looped around the suture end, and attached to the anchor (not shown). (E) The anchor is passed down to the subchondral acetabulum adjacent to the labral tear and securely fastened to the subchondral bone. (F) The result is a double suture loop through the labrum and secured to an anchor in the subchondral bone, leaving the free edge of the labrum intact, continuous, and not everted. (A, acetabulum; Anc, anchor; C, capsule; FH, femoral head; L, labrum.)
through-type labral suture repair compared with a looped-type repair.13 The authors showed significant improvement in the hip fluid seal of through-labral repairs versus loop labral repairs. Table 1 summarizes the distraction force required to overcome the resistance of the hip fluid seal after repair of labral tears using looped- and through-type repairs based on the cadaveric study of Nepple et al.13 We aim to describe a
double-stranded single-pass vertical mattress suture technique for labral repair.
Surgical Technique We use the lateral approach to the hip as previously described.14 In brief, the patient is placed in the lateral decubitus position and the affected hip in traction. Two portals are used for access: the proximal trochanteric
e618
K. YE AND P. J. SINGH Table 2. Advantages and Limitations of Through-Labral Double-Stranded Single-Pass Suture Technique for Arthroscopic Labral Repair Advantages Double suture gives added strength to repair Maintenance of continuous labral free edge to improve labral seal Avoids eversion of labral edge after repair Knotless anchor Limitations Limited use in thin labrums Limited use in labral tears in which free edge is already compromised Non-dissolvable suture
Fig 3. Arthroscopic image of labral repair after femoral head (FH) is engaged in socket. This image, taken during dynamic testing after cam resection, shows the free edge of the labrum forming a complete seal against the femoral head. The vertical arrows show the labrum gliding over the femoral head. The cut suture ends can be seen in the background as indicated by the diagonal arrow showing the repair.
portal and the anterior paratrochanteric portal. A diagnostic arthroscopy is performed to confirm the presence of a labral tear or associated pathologies within the central compartment. An intraportal capsulotomy is performed to gain adequate exposure of the hip joint. In the presence of a labral tear, the acetabular bone adjacent to the labral tear is cleared of soft tissue and a high-speed burr (5.5-mm Dyonics Elite Abrader Burr; Smith & Nephew, London, England) is used to provide a fresh bleeding bony bed for fixation of the labral anchor. Through the anterior portal, the suture loop (FiberLink; Arthrex, Naples, FL) is passed through the midsubstance of the labrum using a sharp suture-passing device (Nanopasser Crescent; Pivot Medical, Sunnyvale, CA). The advantage of using a needle penetratoretype device is that it is less traumatic to the labrum than a bird-beak device. The same device is then passed through the chondrolabral junction to retrieve the suture loop and is brought out of the anterior portal. The loop allows 2 strands to encircle the base of the labrum. Once out of the anterior portal, the free ends of the suture are passed through the loop to create a knot. The acetabulum is then prepared and drilled for anchor placement. The location for anchor placement should be in the subchondral bone close to the articular surface without penetrating the acetabular cartilage. The free ends of the suture are then attached to a knotless anchor and should pass freely
through the anchor to allow tensioning. We use the 2.9mm Quattro Link Knotless Anchor (Cayenne Medical, Scottsdale, AZ). The anchor is placed in the acetabulum and tensioned to restore labral anatomy (Figs 1 and 2). This technique allows the free edge of the labrum to remain continuous and re-establish the suction seal of the labrum. During dynamic testing, the seal can be tested (Fig 3). The entire surgical technique is shown in Video 1, including audio narration.
Discussion The best method for labral repair remains to be proved. Current evidence does not provide a clear, definitive answer and indeed may be difficult to measure. However, if the goal of labral repair is to restore the anatomy and re-establish a seal around the femoral head and neck, leaving the free margin of the labrum intact and continuous without eversion, our technique theoretically achieves this goal. We argue that using a through-labral repair technique may have an advantage over loop suture techniques in achieving these goals. With all labral repairs, it is important to recognize, diagnose, and treat the underlying pathologic process, whether it is cam impingement, pincer impingement, dysplasia, or hyperlaxity. One limitation of all vertical mattressetype sutures is the thickness of the labrum and, therefore, whether using only a portion of the labrum for suture fixation is sufficient, particularly in a degenerative labrum. In our technique, by passing a loop through the labrum, we effectively create a double suture loop at the point of fixation, and this may be an advantage over a single loop in a thin or degenerative labrum. Another advantage of this technique is the use of a knotless anchor system that allows greater manipulation of the tension of the anchor suture. Both over- and undertensioning of the labrum could result in suboptimal restoration of labral anatomy and function. Like other vertical mattress suture techniques, this technique is limited to cases in which the continuous labral free edge is maintained. Table 2 highlights the advantages and limitations of this technique. We argue that arthroscopic
ARTHROSCOPIC DOUBLE-STRANDED LABRAL REPAIR
labral repair of the hip, using a through-labral doublestranded single-pass suture technique with a vertical mattress technique, allows greater versatility to the surgeon in repairing thinner labrums while still achieving a free and continuous free edge.
7.
8.
References 1. Seldes RM, Tan V, Hunt J, Katz M, Winiarsky R, Fitzgerald RH Jr. Anatomy, histologic features, and vascularity of the adult acetabular labrum. Clin Orthop Relat Res 2001;(382):232-240. 2. Ferguson SJ, Bryant JT, Ganz R, Ito K. The acetabular labrum seal: A poroelastic finite element model. Clin Biomech 2000;15:463-468. 3. Ferguson SJ, Bryant JT, Ganz R, Ito K. An in vitro investigation of the acetabular labral seal in hip joint mechanics. J Biomech 2003;36:171-178. 4. Greaves LL, Gilbart MK, Yung AC, Kozlowski P, Wilson DR. Effect of acetabular labral tears, repair and resection on hip cartilage strain: A 7T MR study. J Biomech 2010;43:858-863. 5. Espinosa N, Rothenfluh DA, Beck M, Ganz R, Leunig M. Treatment of femoro-acetabular impingement: Preliminary results of labral refixation. J Bone Joint Surg Am 2006;88:925-935. 6. Krych AJ, Thompson M, Knutson Z, Scoon J, Coleman SH. Arthroscopic labral repair versus selective labral debridement in female patients with femo-
9.
10.
11.
12.
13.
14.
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roacetabular impingement: A prospective randomized study. Arthroscopy 2013;29:46-53. Kelly BT, Weiland DE, Schenker ML, Philippon MJ. Arthroscopic labral repair in the hip: Surgical technique and review of the literature. Arthroscopy 2005;21:1496-1504. Murphy KP, Ross AE, Javernick MA, Lehman RA Jr. Repair of the adult acetabular labrum. Arthroscopy 2006;22:567.e1-567.e3. Available at www. arthroscopyjournal.org. Freehill MT, Safran MR. The labrum of the hip: Diagnosis and rationale for surgical correction. Clin Sports Med 2011;30:293-315. Domb BG, Botser IB. Paper 30: Clinical results of arthroscopic treatment of acetabular labral tears using three methods. Arthroscopy 2012;28:e60-e61 (abstr, suppl 2). Larson CM, Giveans MR. Arthroscopic management of femoroacetabular impingement: Early outcomes measures. Arthroscopy 2008;24:540-546. Fry R, Domb B. Labral base refixation in the hip: Rationale and technique for an anatomic approach to labral repair. Arthroscopy 2010;26:S81-S89 (suppl). Nepple JJ, Philippon MJ, Campbell KJ, et al. The hip fluid sealdPart II: The effect of an acetabular labral tear, repair, resection, and reconstruction of hip stability to distraction. Knee Surg Sports Traumatol Arthrosc 2014;22:730-736. Mason JB, McCarthy JC, O’Donnell J, et al. Hip arthroscopy: Surgical approach, positioning, and distraction. Clin Orthop Relat Res 2003;406:29-37.
