So again, Joe Rysbarski, Mark Philippine's junior partner, he can't be here, so I'm going to present on his behalf, but talk again about labral augmentation. Here are his disclosures. So again, reviewing just some of the anatomy of the labrum, fibrocartilaginous tissue present around the entire lunate surface of the S-tabulum with some attachment to the TAL, which provides its gasket effect, and with its pellets, if I'm most extensive in the capsular portion of the periphery. Looking at scanning electron microscopy, you can see layer three is where the great majority of the circumferential collagen exists, and some of the role of augmentation is to maintain these circular fibers and absorption of the hoop stresses. Just to draw a comparison of the meniscus, the meniscus, although it has a different function, it's richly innervated about the periphery with single axons coursing through the perimeniscal tissue. The nerves are seen on the interstitial tissue on the outer one-thirds. As for the labrum, abundance of free nerve endings also most dense in the anterior superior and posterior superior zones, so the labrum can potentially mediate pain as well as proprioception of the hip joint. Just like treatment of meniscus has evolved over the course of time with total meniscectomy to subtotal, now with meniscus segmental replacements, we've also seen an evolution with the labrum, but we no longer remove all of the meniscus for pain control purposes and try to preserve meniscus tissue as well as labral tissue as much as possible. That's looking at the spectrum of all possible treatments of labrum. The great majority, at least at our center, are labral repair with, in cases of revision when there's remaining circumferential fibers, that's when labral augmentation really has a major role. Some of these goals of preserving labrum to decrease compressive loads of the cartilage matrix and to reduce surface frictions, it's role in proprioception that we're trying to maintain as well as low distribution hip stability. With the ultimate goal of preserving the long-term joint health as well as provide symptomatic relief. This is the treatment algorithm followed. The great majority of cases when there's a labral defect with healthy volume, and I'll get to it later, but the critical number that was seen recently in biomechanics was about a six millimeter labral height. Under those circumstances, repair using various amount of suture anchors is the standard of care in the primary setting. In a revision setting, when sometimes the patient's undergone a previous debridement or whatever happened during the primary case or lysis of adhesions, when there's decreased labral volume, that's when augmentation with iliotube band autograft really plays a role. And then finally, in those rare cases that Dr. Kelly talked about, where there's absence of labrum due to calcification or other, then that's the role for a segmental reconstruction. So what's the difference between a segmental recon and augmentation? Again, segmental recon is used in the rare cases where there's missing segments of viable labral tissue. But for all the rest, when there's viable circumferential fibers and preserved chondrolabral junction, then augmentation is used just to beef up the tissue volume. Again, with the goal of preserving the native vascularization and innervation of the labrum, and the augmentation is just there to provide adequate volume to optimize the suction seal. So this was the paper out of our institution that really saw about six millimeters of labral height as sort of the inflection point on optimization of the distractive forces required for hip distraction. And so that's sort of the goal for, again, the revision setting when there's inadequate labral volume to try to obtain at least six millimeters of labral height. And so it also has a dual role. So not only does it increase tissue volume, but there's a proposed spacer effect of the tissue that exists between the labrum and the capsule, which acts to thwart the creation of capsule labral adhesions, which can potentially act to evert the labrum and disrupt that fluid seal suction seal mechanism. So the technique used at our institution has mostly been focused on a band autograft through a small lateral incision. The graft and size should be about 30 to 40 percent longer than the defect, and most are about a centimeter in width to get the adequate height. When using the iliotibial band autograft, the surgeon usually should release traction, extend the hip and knee, and then internally rotate to allow for maximal IT band visualization. And then an assistant on the back table will tubularize the graft, as you can see in the middle of the video, using absorbable Vicryl. And then finally, the graft is fixed, again, in the prepared bony bed where the rim trimming was performed, as described in this arthroscopy techniques paper, usually using small 1.5 millimeter all suture anchors. Part of it is, as you can see here with piercing in the video to the right, is incorporated into the substance of the remaining labrum. So what evidence is really out there? This was just a case report published from our institution that just showed 7.5 year follow-up after labral augmentation, as you can see in the images to the left. That's sort of what the IT band autograft looked like upon implantation with the prominent Vicryl sutures. And then to the right is the still shot in video of when the patient returned to the operating room about eight years later without, it was a case where it seemed to incorporate some of the graft and also did not have a lot of adhesions present. Histology samples were taken at the time and it showed promising, at least absence of inflammatory cells and seemed like the collagen had survived. This is another paper out of our institution that was actually comparing augmentations matched with reconstruction patients and although there was no difference seen in revision rates or conversion to total hip arthroplasties, the augmentation group trended towards higher patient reported outcome measures, including hip outcome scores, modified adhesive scores and WOMAC scores, a two year follow-up. So this really led a shift towards trying to preserve, again, as much labrum as possible and really use augmentations when possible as opposed to reconstructions. This is some of the data I just presented in the last session, but this is our midterm outcomes following augmentation. So this contained 88 patients with a mean follow-up time of about five years. Again, one of the negatives of this study was that these were revision surgeries and so there were a lot of concomitant pathologies present, including high grade cartilage defects were present in quite a high degree. And so it's hard to tease out exactly the effects of the labral augmentation, but the overall take-home from this publication was that many patients did well with regards to patient reported outcome measures at the five year follow-up with many achieving medically MCIDs and also PATH scores. With good survivorship, additionally, the one, I'd say, concern was about 14% required revision surgery, mostly for adhesions. Three had capsule defects requiring capsule reconstructions, but this led to sort of a second study that looked at autograft versus allografts in both augmentations and reconstructions, sort of a combined group. But the finding of this investigation with a minimum of two year follow-up, which included about 55 allografts and 150 autografts, was that the allografts had about a three times higher rate of revision surgery, mostly primarily due to adhesions. So there may be something in allograft tissue, at least iliotibial band allograft, which is the primary type used that may lead to a higher incidence of postoperative adhesions. So the practices mostly shift to using autograft tissue when doing reconstructions or augmentations. So in conclusion, labral augmentation with iliotibial band autograft should be considered when remaining circumferential fibers exist in the revision setting, and it's key to preserve the chondrolabral junction, vascularization, innervation of the labrum. It seems that iliotibial band autograft seems to be superior to allograft in this single series, but further research is needed. And again, to emphasize exercising caution when proceeding with primary circumferential labor reconstruction, as much more evidence is needed to demonstrate efficacy there. Thank you.

labral augmentation

hip joint surgery

labrum anatomy

joint stability

pain mediation