Welcome to everyone participating in this course. It's really an honor to be a part of. My name is Mike Elman. I'm the Director of Hip Preservation at Panorama Orthopedics and Spine Center in Denver, Colorado. You know, a couple thank yous are certainly in order. First, to Anna for putting this course on, certainly in the middle of a pandemic. To have the dedication to excellence from an education standpoint to continue and to adapt and evolve and allow us to be virtual with our talks, I think it really speaks for itself. So, huge thank you to Anna. Also, I'd like to thank Shane Ngo, Chris Larson, Chad Mather for putting on an excellent course and putting together really an excellent faculty. So, I'm really honored to be part of it. I'm going to be talking about a technical spotlight on labor augmentation of the hip. Here are my disclosures. So, for me in my practice, really the goal of any labral treatment should be based on the principles of labor of labral function. What do I mean by that? Well, every treatment should really be- the goal should be to restore native anatomy, biomechanics, and function of labral tissue. And so, we know that labrum has multiple different properties. It's chondroprotective, protects our underlying cartilage, it provides a hydrostatic fluid layer, allows for proprioception of the hip, and it provides stability to joint distraction. So, in every case, I'm really trying to restore these four main properties of the labrum. From a treatment standpoint as hip arthroscopists, really we have four options. Okay, the first is to debride the labrum or cut it out. Second is to repair the labrum or fix native labral tissue where it's torn off the bone. This is what we're doing in most cases. Third is labral augmentation, where we're actually augmenting an abnormally thin labrum, which we're going to discuss and will be the topic of this spotlight. And the fourth is labral reconstruction, where we're excising the torn labrum and replacing with either allograft or autograft. So, this is a labral treatment algorithm that I basically utilize in every case. So, the first thing you'll- that we're going to do is evaluate the labrum. If the labrum is repairable on the left side of this equation, relatively simple. We're going to go forward with a labral repair. I typically perform labral repairs in the vast majority of our primary cases. However, on the other side of this algorithm, so if the- if the labrum happens to be irreparable or a patient presents with severe hypoplasia, we really have three options. We can either debride that labrum, we can augment it or bulk it up, or we can reconstruct it. For the purposes of this talk, we're going to be focusing on labral augmentation of the hip. Labral augmentation really is- recently emerged as an alternative to labral reconstruction, the setting of a hypoplastic labrum in either a primary revision setting. So, essentially what we're doing is we're putting graft, whether it's allograft or autograft, behind the native labrum, suturing it to the labrum and the bone itself to provide a thicker, more robust labrum and a better suction seal. Now, the benefits are numerous. The advantage of augmentation over reconstruction is we're preserving the chondrolabral junction, so we're protecting that underlying cartilage. We're allowing for proprioceptive fibers of the native labrum to stay intact. We're preserving labral hoop stresses. So, going back to our earlier slide on the native biome- on restoring the native biomechanics of the hip, labral augmentation actually can do a very nice job of that. And the fourth thing is, you know, theoretically we're preserving the labrum, so we'll preserve some of the vascular supply to it, which can aid in graft incorporation. What are risks? Well, if we're preserving poor quality native labral tissue, then patients can present with persistent pain and disability with or without instability if we're unable to restore a seal. So, what are indications for labral augmentation? Well, frankly, they're still evolving. So, my specific indications for an augmentation are a patient with a hypoplastic labrum, less than three to four millimeters of width, an intact chondrolabral junction, young active patient with good-looking cartilage. Typically, I'm performing these procedures in a revision setting, but but they may be indicated in a primary case as well. If I can't get an excellent suction seal using our standard labral advancement techniques in cases such as a profunda hip with a partially ossified very thin labrum where I want to maintain stability in a young patient, augmentation certainly may be indicated. From a technique standpoint, there's really no right answers. There's a recently described technique. I think it's important you find something that works for you in your hands and stick with it. Just know there will be a learning curve to it. It's difficult. It's not as difficult as labor reconstruction because the labor room is still there. But there is still a learning curve that you've got to work through. There are certainly variations in technique. Ben Doan published a nice technique guide on his technique for labor augmentation, Mark Philippon did the same on his technique. We've recently submitted our technique guide for labor augmentation of the hip to arthroscopy techniques and hope to have that available to you guys in the next couple months on PubMed. Certainly variations in the type of graft you can use as well as front to back versus segmental. In general, I would say a vast majority of the time, most of these areas of hypoplasia are segmental in nature. They're not front to back all the way around or circumferential. So we typically do segmental labor augmentation procedures. Our technique for labor augmentation really is based on our technique for hip labor reconstruction, which is called the kite technique that we published back in 2016 in ATAC. We've taken a lot of the same principles from our kite technique for reconstruction and applied them to augmentation. Really, this is a segmental augmentation using tibialis anterior allograft. I'll make it a bit thinner than we do in a reconstruction, only about 4 to 5 millimeters of width, as opposed to 5 to 7 millimeters in a recon. We're typically averaging about 4 to 6 anchors for about a 40 to 60 millimeter graft, which is about 1 anchor per 8 to 10 millimeters. And here's a basic overview of our labral augmentation technique. So essentially what you're doing is you're throwing anchors behind the native labrum. And basically you just take one suture from the anterior segment anchor, one suture from the posterior segment anchor, colored in red and green here respectively, pulling them out of a cannula and piercing them through your graft. The way we do it, or we prefer to do it, is we actually tie kind of a mulberry knot or multiple half hitches at the end of those sutures. And those knots actually will just pull your graft into place along the rim. And get us situated once we get the graft into place. So here's our video for our labral augmentation technique. So essentially you start with a diagnostic arthroscopy. I do utilize four portals, our standard anterolateral and mid-anterior portal. We use two accessory portals, a proximal mid-anterior portal for suture storage, and a dollop portal to put our anchors in. So the first thing we'll do is start out with our diagnostic scope. In this patient you can see a labral tear anterior superiorly, but you can also see a nice well-defined labrum and posterior inferiorly and anterior inferiorly. And the labrum is pretty severely hypoplastic here, only about three millimeters in width. What we'll do is we first clean up behind the labrum, we'll perform our acetabuloplasty if indicated. And you can see here diagnostically where the patient has a poor native suction seal in the region of labral hypoplasia. And so once we make our decision to proceed with our augmentation, the first step after cleaning it up and doing your rim trim is to place your anchors. So I'll place my anchors using a curved guide, using a small anchor, typically 1.4 millimeter anchor, off the capsular side of the native labrum as close to the edge of the rim as possible to restore our suction seal. I'll separate them by about eight millimeters. From a suture storage standpoint, I'll store our mid-body sutures at the proximal mid-anterior portal, our anterior segment anchor sutures at the mid-anterior portal, and our posterior segment sutures at the anterolateral portal. We'll then proceed with measuring the segment defect. This is well described in our kite measurement technique that was published last year, in arthroscopy technique, so you guys can look it up. But essentially, what you're doing is you're tying the anterior-most anchor suture and posterior-most anchor suture together. We're using a ruler just to make hash marks. And then you line it up along the rim, and it essentially forms a bridge in your segment to give you your exact measurement. So then we prepare our graft, that length, and we pass our sutures, as you can see here. So we'll pass our anterior-most suture, which is the red suture, through the anterior end of the graft, posterior through the posterior end of the graft, tie our mulberry knot, color the end just to make it easy to retrieve, and then we just pass it into the joint. So we're pulling on the corresponding suture limbs to pulley that graft into the joint. And just like a reconstruction, this is going to just do the work for us. So the sutures, the knots, will actually pull that graft into the joint. I like to pull it into the joint off of traction here. Then once we get the graft in, I'll actually come back onto traction. And now we're going to just focus on tacking down the anterior portion of the graft to the labrum and to the acetabulum. So I'll pass the corresponding suture. You have one end through the graft itself. That's what brought the graft in. That's our post. The other end is going to go around the native labrum and the graft, and we'll tack down our anterior suture end and tack down the anterior allograft tissue. The key to any segmental technique, guys, is getting the ends tied down first because once you do that, it's really just a glorified labor repair. So now we're working posteriorly. So I've switched my camera to the mid-anterior portal, looking backwards, looking back at the posterolateral aspect of the acetabulum. Again, we put one suture through the native labrum and around the graft and one through the graft itself, which will be our post, and we tie that down. Once we get here, it's relatively straightforward. You've just got to tie down posteriorly. Your ends are then tied, as you can see here. We'll come in, we'll cut these sutures, and then we're just securing the mid-body of the graft using our previously passed anchors that are stored on our proximal mid-anterior portal. So we'll take one suture and we'll loop it around both the graft and the labrum itself at the chondrolabral junction, and we'll tie this down. So you can see that coming up here, and this is kind of our final labral augmentation here. You can see that previously thin labrum is now much more robust. It's nice and sturdy and stable, attached both to rim as well as labrum. And here's our suction seal. So we come off traction, then we'll come back on, and you can see restoration of a nice suction seal in this patient and restoration of stability. From an outcome standpoint, really few studies to date, which makes sense. I mean, this is a very new procedure. Mark Philippon has the most well-cited study from arthroscopy in 2018. We actually compared 33 patients with labral augmentation to 66 patients with a reconstruction. We found that the augmentation patients actually did better with regards to multiple patient-reported outcomes, as you can see here, but there was no difference in revision rate or conversion to total HIP. So what are our mid- and long-term outcomes of labral augmentation? Frankly, it's a good question. We have no idea, and we're still very early in the process of learning about labral augmentations from a biomechanical standpoint and a functional standpoint, so certainly more work to be done. So in summary, labral augmentation is an exciting option for the right patient. Generally, young active patients, hypoplastic labrum with an intact chondrolateral junction and good-looking cartilage. To me, it shouldn't be used really as a primary procedure when the labrum is repairable primarily to an excellent seal, but we have used it in the rare primary setting where we can't get a nice seal and the patient has a severely hypoplastic labrum. Optimal technique is, you know, still up for debate. Certainly find something that works for you. The kite technique in our hands has provided efficient reproducible outcomes and I've been very happy with it. Certainly more research is needed to validate our techniques and our outcomes. Thank you.

labral augmentation

hip preservation

native anatomy

biomechanics

labral treatment