Abstract
Our recent understanding of the importance of the acetabular labral suction seal has placed preserving labral integrity as a guiding principle in hip preservation surgery. In cases with a hypoplastic labrum and intact chondrolabral junction, labral augmentation presents as a viable alternative and an often preferred treatment option over labral reconstruction. At this time, there are few studies that have described the technical pearls of performing labral augmentation of the hip. In this technique guide, we describe, in detail, the kite technique for the introduction, control, and acetabular fixation of a hip labral augmentation graft. Comparable to flying a kite with 2 fly lines and to the previously described kite technique for hip labral reconstruction, the kite technique for labral augmentation is based on the principle that the use of 2 control sutures in a pulley system creates an efficient method to accurately and reproducibly facilitate graft passage and fixation during arthroscopic labral augmentation procedures.
Technique Video
Kite technique for efficient graft management and fixation during arthroscopic hip labral augmentation shown in a left hip in the supine position. With the operative leg placed under traction, a standard diagnostic arthroscopy is performed via the proximal anterolateral portal (ALP) and the midanterior portal (MAP). After a standard hip arthroscopy, the hip is positioned into traction to allow for access to the central compartment. With the arthroscope placed within the ALP, a full assessment of the labrum is completed, assessing for pathology of the native labral tissue. When we elect to perform a labral augmentation, the labrum is typically hypoplastic, with a width of 2 to 4 mm, a poor native suction seal, and an intact chondrolabral junction. The region of labral hypoplasia is often segmental and rarely involves the entirety of the labrum, and therefore, a segmental augmentation is performed. During assessment of the labrum, an absent suction seal is identified. With a large adjustable cannula (Pivot TransPort 789 cannula, 110-140 mm; Stryker) inserted into the distal anterolateral accessory (DALA) portal, suture anchors (1.4-mm NanoTack anchors) are sequentially placed approximately 8 mm apart along the acetabular rim, just proximal to the hypoplastic labrum. Care should be taken to avoid perforating the articular cartilage. Ideally, the drill guide should push directly against the capsular side of the native labrum to ensure appropriate graft placement and restoration of the suction seal. The anchor sutures are organized with the anterior anchor sutures stored in the midanterior portal, midbody sutures within the accessory proximal midanterior portal, and posterior anchor sutures within the ALP, adjacent to the arthroscope. One suture strand from the anterior and posterior anchors is then retrieved via the DALA cannula for the kite measurement technique. The sutures within the DALA cannula are tied together, leaving a 1- to 2-cm suture tail, and hash marks with 5-mm increments are placed along the posterior strand, starting from the knot and spanning the length of labral hypoplasia. The knot is then transferred into the joint and placed directly over the anterior anchor. A suture bridge is formed between the 2 end anchors using a probe, allowing for accurate and reproducible measurement for graft preparation. A labral graft is then prepared using tibialis anterior allograft as previously described. One suture strand from the anterior- and posterior-most anchors is retrieved from the DALA cannula. A free needle is then used to pierce these sutures into their respective ends of the graft. Multiple half-hitches are thrown to create a knot onto each respective suture strand, leaving a tail of approximately 1 cm. The tails of each suture strand are colored to allow for easy identification once the graft is placed into the joint. At this time, the graft is inserted into the joint using the kite technique. The 2 end-anchor corresponding sutures, 1 out of the MAP and 1 out of the ALP, are sequentially tensioned, similarly to fly lines on a kite, and the knots on the ends of the anterior and posterior sutures effectively pull each end of the graft through the DALA cannula into position along the rim. An arthroscopic grasper and probe may be used to aid in positioning the graft, but typically, this is not necessary. Once the graft is provisionally placed along the rim adjacent to the native labrum, the anterior anchor sutures are retrieved via the MAP. The suture previously passed through the graft will be the post suture for tying. The corresponding suture strand is then looped around both the native labrum and graft by piercing through the chondrolabral junction, similarly to a labral repair, and tied using standard knot-tying techniques, securing the anterior end of the graft. Via the DALA portal, the posterior sutures are retrieved, and the posterior end is secured in a similar fashion. Once the ends of the graft are secured to both bone and the native labrum, the midbody sutures are retrieved sequentially, looped around both the labrum and graft, and tied using a standard technique to secure the augmented labral graft into place. After fixation of the graft, traction is released, and a dynamic examination is performed to verify that the augmentation is stable, the impingement is adequately decompressed, and the suction seal is restored. To complete the procedure, the anterior portion of the capsule is closed per a standard technique.
Our recent understanding of the importance of the acetabular labral suction seal has placed preserving labral integrity as a guiding principle in hip preservation surgery.1, 2, 3, 4 Clinical studies have shown a faster progression of hip arthritis in patients who have previously undergone partial labral resection.5 In patients with deficient labral tissue—commonly the result of chronic impingement causing ossification, a degenerative or hypoplastic native labrum, iatrogenic causes, or revision cases—labral augmentation and reconstruction have emerged as viable alternative solutions to labral repair for symptoms of microinstability, pain, and discomfort in both primary and revision settings.6, 7, 8
Since its introduction by Philippon et al.,8 arthroscopic labral reconstruction has proved to be an essential tool for preserving native hip function and integrity. Although this procedure was originally described using fascia lata autograft, several techniques for segmental and circumferential reconstruction have been described, with a multitude of allografts and autografts, with good to excellent outcomes.9, 10, 11, 12, 13, 14, 15 In contrast, cadaveric biomechanical studies have shown improved restoration of the hip joint fluid suction seal with labral preservation versus labral reconstruction.16
In cases with a hypoplastic labrum and intact chondrolabral junction, labral augmentation presents as a viable alternative and an often preferred treatment option over labral reconstruction.7 Labral augmentation involves placement and fixation of either autograft or allograft tissue proximal and adjacent to the native labrum, essentially creating a larger, thicker labrum allowing for a more robust suction seal. The advantages of labral augmentation over reconstruction include (1) maintenance of the chondrolabral junction, decreasing the risk of damage to the acetabular cartilage; (2) maintenance of the native proprioceptive fibers of the native labrum; and (3) avoidance of disruption of labral hoop stresses if a segment of the labrum is excised in a reconstruction.
Despite the growing interest in labral augmentation, many of the technical considerations of this procedure have yet to be elucidated in the literature. Previously, the “kite technique” was developed for the introduction, control, and efficient fixation of a segmental labral reconstruction graft.15,17 Similarly to flying a kite with 2 fly lines, the principles of this method are founded on the belief that a soft-tissue graft in an arthroscopic environment is safe, efficient, and easy to guide into position with 2 control sutures using a pulley system. This technique may be reproduced with labral augmentation procedures with some important differences, as we introduce the kite technique for arthroscopic fixation of a labral augmentation graft.
Indications
The indications for labral augmentation include (1) a hypoplastic labrum (<3 mm wide) with symptoms of instability and a poor native suction seal; (2) an intact chondrolabral junction; and (3) a young, active patient. Augmentation procedures are typically reserved for revision procedures but may be indicated in rare primary cases if an adequate seal is unable to be achieved with a primary repair using labral advancement techniques.
Surgical Technique
Patient Positioning and Anesthesia
After general anesthesia is induced, the patient is positioned supine on a post-free distraction table (Pivot Guardian Distraction System; Stryker, Kalamazoo, MI) with all bony prominences appropriately padded. The operative leg is placed in a neutral position (Fig 1). Post-free distraction affords the benefit of excellent distraction by using Trendelenburg positioning of the bed while negating the risk of iatrogenic pudendal nerve palsy or perineal soft-tissue compression.
Fig 1.
Patient positioning. The patient is placed supine on a post-free distraction table, and the operative leg (left leg in photograph) is put into traction in a neutral position. The perineum and all bony prominences are appropriately padded.
Diagnostic Arthroscopy
The operative leg is placed under traction, and fluoroscopy is used to guide entry into the hip joint via the anterolateral portal (ALP). Four standard arthroscopic portals are used: the ALP, a midanterior portal (MAP), a proximal midanterior portal (PMAP) located 3 cm proximal to the MAP to allow for suture storage, and a distal anterolateral accessory (DALA) portal created 3 to 4 cm distal and 1 to 2 cm anterior to the ALP (Fig 2). An interportal capsulotomy is performed between the MAP and ALP, with care to preserve at least 1 cm of acetabular capsular remnant tissue for closure or plication at the conclusion of the case.
Fig 2.
Intraoperative photograph of a left hip, in the supine position, showing the location of the portals and their relation to the greater trochanter. (ALP, anterolateral portal; DALA, distal anterolateral accessory portal; MAP, midanterior portal; PMAP, proximal midanterior portal.)
The surgeon performs a standard diagnostic arthroscopy, noting the size and quality of the native labrum and labral tear, status of the articular cartilage, and presence or absence of an adequate suction seal. If the labrum is of adequate quality, a labral repair is performed using previously described techniques.4 However, if the labral tissue is inadequate for repair but amenable for augmentation based on our specified indications described earlier, a decision for augmentation is made.
Acetabuloplasty
The interval between the proximal capsule and labrum is first developed using a mechanical shaver and radiofrequency probe. We prefer to perform this step with the patient's hip flexed to 25°, off traction, with suspension sutures placed within the proximal capsular leaflet to better preserve this tissue for later repair. A standard acetabuloplasty is performed to reshape the acetabular rim and eliminate the pincer lesion as necessary, thereby providing a bleeding environment amenable for graft incorporation.
Femoroplasty
A femoral osteochondroplasty is performed to correct the head-neck offset and eliminate cam impingement. During this step, 2 traction sutures are placed in the distal leaflet of the capsule to ensure adequate visualization of the anterior, superior, and distal femoral head-neck junction.
Labral Augmentation
The hip is placed into traction to allow for access to the central compartment. As previously noted, when we elect to perform an augmentation, the labrum is typically hypoplastic (2 to 4 mm) with a poor native suction seal and intact chondrolabral junction. Therefore, as opposed to a labral reconstruction in which the damaged labrum is completely excised, care is taken in this case to avoid damage to the native labral tissue. The region of labral hypoplasia is often segmental and rarely involves the entirety of the labrum, and therefore, a segmental augmentation is performed using the kite technique.
The area of hypoplasia requiring augmentation is evaluated and spanned with suture anchors. Multiple anchors (1.4-mm NanoTack anchors; Stryker) are sequentially placed around the acetabular rim using a curved guide via the DALA portal without breaching the joint (Fig 3), just proximal to the labrum. The anchors are spaced approximately 8 mm apart along the rim, spanning the segment of labral hypoplasia. In most cases, the drill guide should push directly against the capsular side of the native labrum during anchor placement to ensure proper graft placement and restoration of a robust suction seal. In some cases in which the native labrum requires advancement to achieve a suction seal, the anchors are placed via an intra-articular, inside-out approach, with the drill guide placed at the chondrolabral junction within the joint on the articular side of the native labrum.
Fig 3.
Intraoperative photograph showing the placement of the anterior, midbody, and posterior anchors along the acetabular rim in a left hip, in the supine position, with the arthroscope in the anterolateral portal. The anchors are sequentially placed approximately 8 mm apart along the acetabular rim, just proximal to the hypoplastic labrum.
Suture Management
The anterior-segment anchor suture limbs are retrieved from the MAP and stored. The midbody sutures are retrieved from the proximal midanterior portal (PMAP) for suture storage until final graft fixation later in the case. The posterior-segment anchor suture limbs are retrieved from the ALP (adjacent to the arthroscope). This facilitates measurement, graft passage, and graft fixation while minimizing the risk of suture entanglement (Fig 4).
Fig 4.
Illustrated diagram (A) and intraoperative photograph (B) showing intraoperative suture organization in a left hip in the supine position. The anchor sutures are organized with the anterior anchor sutures (red) stored in the midanterior portal (MAP), midbody sutures (black) within the proximal midanterior portal (PMAP), and posterior anchor sutures (green) within the anterolateral portal (ALP), adjacent to the arthroscope. One suture strand from the anterior and posterior anchors is then retrieved via the distal anterolateral accessory portal (DALA) cannula for the kite measurement technique.
Measurement Technique
Similarly to a labral reconstruction, we prefer to use the previously described kite measurement technique17 to measure graft length in augmentation procedures. This technique allows for easy measurement of a segmental defect using 2 tied sutures, 1 from each end anchor, via a pulley system, to create a suture “bridge,” allowing for an accurate and reproducible measurement for graft preparation (Fig 5).17 The steps for the kite measurement technique are shown in Video 1.
Fig 5.
Intraoperative photograph showing the suture bridge formed between the anterior and posterior suture anchors during the kite measurement technique viewed through the anterolateral portal in a left hip in the supine position. The hash marks in 5-mm increments placed along the posterior strand are counted for accurate and reproducible measurement for graft preparation.
Graft Preparation
We prefer a tibialis anterior allograft (AlloSource, Centennial, CO) for labral augmentations, but various autograft and allograft tissues have been described as acceptable alternatives.7,18,19 After thawing and measurement to the appropriate length, as noted earlier, the graft is tubularized to 4 to 5 mm in diameter and whipstitched with several No. 2-0 Vicryl sutures (Ethicon, Somerville, NJ), as previously described (Fig 6).20
Fig 6.
Intraoperative image showing the prepared tibialis anterior allograft. After thawing and measurement to the appropriate length, as noted from the kite measurement technique, the tibialis anterior allograft is tubularized to 4 to 5 mm in diameter and whipstitched with several No. 2-0 Vicryl sutures. A free needle is used to pierce 1 suture strand from both the anterior and posterior suture anchors into their respective ends of the graft. Multiple half-hitches are thrown to create a knot onto each respective suture strand, leaving a tail of approximately 1 cm. The tails of each suture strand are colored to allow for easy identification once the graft is placed into the joint.
Graft Insertion
The graft is inserted and fixed using similar principles to the kite technique for labral reconstruction, as previously described.15 A second cannula is inserted into the MAP to aid with suture passage and knot tying. One suture limb from the anterior anchor and one from the posterior anchor are retrieved from the DALA cannula. The graft is positioned outside the DALA cannula. With a free needle, the anterior anchor suture strand out of the DALA portal is pierced through one end of the graft, and multiple half-hitches are thrown to create a knot to itself at the end of the suture, leaving a tail of approximately 1 cm. The same procedure is performed for the posterior anchor suture, as it is pierced through the opposite end of the graft with a free needle and tied to itself (Fig 7).
Fig 7.
Illustrated diagram depicting the kite technique for labral augmentation graft passage in a left hip in the supine position. The red and green sutures represent the sutures from the anterior and posterior anchors, respectively. These sutures are tied onto themselves with multiple half-hitches on their respective ends of the graft. The post ends of these sutures, with the anterior ones stored in the midanterior portal (MAP) and the posterior ones stored in the anterolateral portal (ALP), are alternatingly tensioned during the kite technique for graft passage to effectively pull each end of the graft through the distal anterolateral accessory portal (DALA) cannula into position along the rim. The black sutures represent the midbody anchor sutures, which are stored within the proximal midanterior portal (PMAP) for final graft fixation.
At this time, the graft is inserted into the joint using the kite technique. The 2 corresponding suture strands from the anterior and posterior anchors, 1 out of the MAP and 1 out of the ALP, are alternatingly tensioned, similarly to fly lines on a kite, and the knots on the ends of the anterior and posterior sutures effectively pull each end of the graft into position along the rim. An arthroscopic grasper and probe may be used to aid in positioning the graft, but typically, this is not necessary. Once the graft is provisionally placed along the rim proximal to the native labrum, the anterior anchor sutures are retrieved. The sutures that are pierced through the graft are now termed the post sutures. The non-post, free suture is then looped around both the native labrum and graft by piercing through the chondrolabral junction, similarly to a labral repair, and tied using standard knot-tying techniques, securing the anterior end of the graft. The posterior end is secured in similar fashion via the DALA portal. This is a key difference from labral reconstruction procedures because augmentation requires an additional step of passing the suture under the labrum and/or graft prior to tying, with a vertical mattress configuration through the graft and labrum together and the knot aligned against the graft. Once the ends of the graft are secured to both bone and the native labrum, the midbody sutures are retrieved sequentially, looped around both the labrum and graft, and tied using a standard technique to secure the augmented labral graft into place (Fig 8).
Fig 8.
Intraoperative photograph showing final graft fixation (A) and restoration of the suction seal viewed through the anterolateral portal in a left hip in the supine position.
After fixation of the graft, traction is released, and a dynamic examination is performed to verify that the augmentation is stable, the impingement is adequately decompressed, and the suction seal is restored. To complete the procedure, the anterior portion of the capsule is closed per a standard technique. Pearls for the kite technique for labral augmentation are summarized in Table 1.
Table 1.
Pearls for Kite Technique in Labral Augmentation of Hip
| Preparation |
| Traction sutures are placed in the proximal capsular leaflet to preserve capsular integrity for later repair, as well as improve exposure and visualization. |
| Anchor insertion and the kite measurement technique are performed with the hip in traction. |
| Suture management |
| The anterior anchor sutures are stored within the MAP. |
| The midbody sutures are stored within the PMAP. |
| The posterior anchor sutures are stored within the ALP adjacent to the arthroscope. |
| Graft passage and fixation |
| The dam should be cut out of the DALA cannula to facilitate graft passage. |
| Retrieval of 1 strand of anterior anchor suture, followed by 1 strand of posterior anchor suture, should be performed via the DALA cannula. |
| Prior to placing sutures into the graft with a free needle, the surgeon should ensure that the suture strands are not crossed within cannula. |
| Each end of the graft should be pierced outside of the joint with the respective suture because attempting to pierce the graft after graft passage into the joint may induce iatrogenic damage to the native labrum, graft, or capsule. |
| Knots should be tied at the end of each suture after the graft is pierced because these knots will be used to “pulley” the graft into the joint via the kite technique. |
| The graft should be inserted with the hip in 20° of flexion to relax the proximal capsular remnant and allow for excellent visualization. |
| The suture piercing the graft will be the post suture for tying, while the opposite strand should be passed around the graft and labrum through the chondrolabral junction to secure the graft and labrum to bone. |
| The remaining midbody sutures should be placed around the graft and/or labrum similarly to standard labral repair. |
ALP, anterolateral portal; DALA, distal anterolateral accessory portal; MAP, midanterior portal; PMAP, proximal midanterior portal.
Postoperative Rehabilitation
Postoperatively, the patient is restricted to 20 lb of partial weight bearing for 6 weeks with standard hip arthroscopy precautions, as previously described for labral reconstruction of the hip.15
Discussion
This Technical Note outlines our preferred method for labral augmentation, using the kite technique for safe and efficient graft passage and enhanced control of the soft-tissue graft within the joint. The kite technique for labral augmentation allows for immediate, anatomic fixation of the graft ends and ease of graft fixation with pre-placed midbody anchors. The end result is restoration of the labral suction seal, maintenance of the chondrolabral junction, and conservation of the native labrum's circumferential fibers while increasing the efficiency of this technically demanding procedure.
In cases with a hypoplastic labrum and intact chondrolabral junction, labral augmentation presents as a viable alternative and an often preferred treatment option over labral reconstruction.7 In particular, a recent study by Philippon et al.21 showed a significantly higher Hip Outcome Score–Activities of Daily Living and Hip Outcome Score–Sports in patients undergoing labral augmentation compared with labral reconstruction. However, no statistically significant differences in revision or conversion to total hip arthroplasty were reported for either group.
The proposed benefits of labral augmentation over reconstruction include (1) maintenance of the chondrolabral junction, decreasing the risk of damage to the acetabular cartilage; (2) maintenance of the proprioceptive fibers of the native labrum; (3) maintenance of labral hoop stresses by not severing the circumferential fibers as is commonly done in reconstruction; and (4) maintenance of the native labrum's vascular supply, which may aid in graft incorporation.
To date, there are 2 commonly described techniques for hip labral augmentation in the literature.7,19 In contrast to the technique described by Locks et al.,7 our technique uses tibialis anterior allograft as opposed to iliotibial band allograft or autograft. This simplifies graft preparation, and tibialis anterior allograft has been shown to be equivalent biomechanically to iliotibial band grafts and the native labrum.22 Furthermore, relative to the techniques of Locks et al. and Maldonado et al.,19 graft passage into the joint is simplified by use of the kite technique. Rather than securing the free graft end after graft passage into the joint, our technique allows for immediate, anatomic fixation of both graft ends prior to shuttling the graft into the joint. This increases the ease with which labral augmentation is performed by increasing control of the graft inside the joint. Thus, when the allograft is shuttled into the joint, the allograft is immediately placed in the desired position to more easily complete the remaining fixation.
The kite technique for labral augmentation is not without limitations. First, this technique is intended for use during labral augmentation only. For patients with a completely deficient labrum or a segmental labral defect, labral reconstruction remains the gold standard. The kite technique for labral augmentation relies on accurate measurements of the labral segment to be augmented. Although making accurate measurements can be technically challenging, we have provided our reproducible technique for accurately measuring the desired segment. Additionally, labral augmentation entails an increased cost compared with labral repair because of allograft use. Finally, there is a learning curve with this technique to prevent suture entanglement and to minimize trauma or disruption of the allograft tissue. This learning curve is estimated at approximately 5 to 10 cases, which is a relatively high number for a rare procedure. Advantages and limitations of the kite technique for labral augmentation can be found in Table 2.
Table 2.
Advantages and Limitations of Kite Technique in Labral Augmentation of Hip
| Advantages |
| Enhanced control of soft-tissue graft within joint |
| Precise measurement using kite measurement technique decreases risk of graft-defect mismatch |
| Anterior and posterior anchor suture passed into graft outside of joint to avoid iatrogenic injury to graft, labrum, and capsule |
| Reproducible, simple kite entry technique with immediate graft end fixation—easing technical difficulty |
| Limitations |
| Requirement for accurate measurement of defect size to avoid graft-defect mismatch |
| Only intended for cases with segmental (not global) labral hypoplasia |
| Increased cost compared with labral repair because of allograft use |
| Learning curve estimated at 5-10 cases |
In conclusion, the kite technique offers an efficient, safe, and reproducible method for labral augmentation. Using the described technique, we have noted improved consistency and efficiency in performing this technically demanding procedure. To date, mid- and long-term outcomes of this technique are not yet available, but the technical pearls presented in this study may help to improve efficiency, reduce operative time, and provide excellent and secure fixation of labral augmentation grafts.
Footnotes
The authors report the following potential conflicts of interest or sources of funding: S.B. receives instructor fees for hip arthroscopy training in courses from Graymont Medical - Chicago, Illinois; reports ownership/stock options in Joint Preservation Innovations; owns stock in Vericel; owns stock or stock options in Edge Surgical; and receives nonfinancial support from OJM Financial Counseling as coauthor of the book Wealth Planning for the Modern Physician: From Residency to Retirement, outside the submitted work. In addition, S.B. has a patent pending for Surgical Rotary Cutting Tool Including Articulable Head. M.B.E. receives support for education and consulting from Stryker Endoscopy and Sports Medicine, outside the submitted work. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
Supplementary Data
Kite technique for efficient graft management and fixation during arthroscopic hip labral augmentation shown in a left hip in the supine position. With the operative leg placed under traction, a standard diagnostic arthroscopy is performed via the proximal anterolateral portal (ALP) and the midanterior portal (MAP). After a standard hip arthroscopy, the hip is positioned into traction to allow for access to the central compartment. With the arthroscope placed within the ALP, a full assessment of the labrum is completed, assessing for pathology of the native labral tissue. When we elect to perform a labral augmentation, the labrum is typically hypoplastic, with a width of 2 to 4 mm, a poor native suction seal, and an intact chondrolabral junction. The region of labral hypoplasia is often segmental and rarely involves the entirety of the labrum, and therefore, a segmental augmentation is performed. During assessment of the labrum, an absent suction seal is identified. With a large adjustable cannula (Pivot TransPort 789 cannula, 110-140 mm; Stryker) inserted into the distal anterolateral accessory (DALA) portal, suture anchors (1.4-mm NanoTack anchors) are sequentially placed approximately 8 mm apart along the acetabular rim, just proximal to the hypoplastic labrum. Care should be taken to avoid perforating the articular cartilage. Ideally, the drill guide should push directly against the capsular side of the native labrum to ensure appropriate graft placement and restoration of the suction seal. The anchor sutures are organized with the anterior anchor sutures stored in the midanterior portal, midbody sutures within the accessory proximal midanterior portal, and posterior anchor sutures within the ALP, adjacent to the arthroscope. One suture strand from the anterior and posterior anchors is then retrieved via the DALA cannula for the kite measurement technique. The sutures within the DALA cannula are tied together, leaving a 1- to 2-cm suture tail, and hash marks with 5-mm increments are placed along the posterior strand, starting from the knot and spanning the length of labral hypoplasia. The knot is then transferred into the joint and placed directly over the anterior anchor. A suture bridge is formed between the 2 end anchors using a probe, allowing for accurate and reproducible measurement for graft preparation. A labral graft is then prepared using tibialis anterior allograft as previously described. One suture strand from the anterior- and posterior-most anchors is retrieved from the DALA cannula. A free needle is then used to pierce these sutures into their respective ends of the graft. Multiple half-hitches are thrown to create a knot onto each respective suture strand, leaving a tail of approximately 1 cm. The tails of each suture strand are colored to allow for easy identification once the graft is placed into the joint. At this time, the graft is inserted into the joint using the kite technique. The 2 end-anchor corresponding sutures, 1 out of the MAP and 1 out of the ALP, are sequentially tensioned, similarly to fly lines on a kite, and the knots on the ends of the anterior and posterior sutures effectively pull each end of the graft through the DALA cannula into position along the rim. An arthroscopic grasper and probe may be used to aid in positioning the graft, but typically, this is not necessary. Once the graft is provisionally placed along the rim adjacent to the native labrum, the anterior anchor sutures are retrieved via the MAP. The suture previously passed through the graft will be the post suture for tying. The corresponding suture strand is then looped around both the native labrum and graft by piercing through the chondrolabral junction, similarly to a labral repair, and tied using standard knot-tying techniques, securing the anterior end of the graft. Via the DALA portal, the posterior sutures are retrieved, and the posterior end is secured in a similar fashion. Once the ends of the graft are secured to both bone and the native labrum, the midbody sutures are retrieved sequentially, looped around both the labrum and graft, and tied using a standard technique to secure the augmented labral graft into place. After fixation of the graft, traction is released, and a dynamic examination is performed to verify that the augmentation is stable, the impingement is adequately decompressed, and the suction seal is restored. To complete the procedure, the anterior portion of the capsule is closed per a standard technique.
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Supplementary Materials
Kite technique for efficient graft management and fixation during arthroscopic hip labral augmentation shown in a left hip in the supine position. With the operative leg placed under traction, a standard diagnostic arthroscopy is performed via the proximal anterolateral portal (ALP) and the midanterior portal (MAP). After a standard hip arthroscopy, the hip is positioned into traction to allow for access to the central compartment. With the arthroscope placed within the ALP, a full assessment of the labrum is completed, assessing for pathology of the native labral tissue. When we elect to perform a labral augmentation, the labrum is typically hypoplastic, with a width of 2 to 4 mm, a poor native suction seal, and an intact chondrolabral junction. The region of labral hypoplasia is often segmental and rarely involves the entirety of the labrum, and therefore, a segmental augmentation is performed. During assessment of the labrum, an absent suction seal is identified. With a large adjustable cannula (Pivot TransPort 789 cannula, 110-140 mm; Stryker) inserted into the distal anterolateral accessory (DALA) portal, suture anchors (1.4-mm NanoTack anchors) are sequentially placed approximately 8 mm apart along the acetabular rim, just proximal to the hypoplastic labrum. Care should be taken to avoid perforating the articular cartilage. Ideally, the drill guide should push directly against the capsular side of the native labrum to ensure appropriate graft placement and restoration of the suction seal. The anchor sutures are organized with the anterior anchor sutures stored in the midanterior portal, midbody sutures within the accessory proximal midanterior portal, and posterior anchor sutures within the ALP, adjacent to the arthroscope. One suture strand from the anterior and posterior anchors is then retrieved via the DALA cannula for the kite measurement technique. The sutures within the DALA cannula are tied together, leaving a 1- to 2-cm suture tail, and hash marks with 5-mm increments are placed along the posterior strand, starting from the knot and spanning the length of labral hypoplasia. The knot is then transferred into the joint and placed directly over the anterior anchor. A suture bridge is formed between the 2 end anchors using a probe, allowing for accurate and reproducible measurement for graft preparation. A labral graft is then prepared using tibialis anterior allograft as previously described. One suture strand from the anterior- and posterior-most anchors is retrieved from the DALA cannula. A free needle is then used to pierce these sutures into their respective ends of the graft. Multiple half-hitches are thrown to create a knot onto each respective suture strand, leaving a tail of approximately 1 cm. The tails of each suture strand are colored to allow for easy identification once the graft is placed into the joint. At this time, the graft is inserted into the joint using the kite technique. The 2 end-anchor corresponding sutures, 1 out of the MAP and 1 out of the ALP, are sequentially tensioned, similarly to fly lines on a kite, and the knots on the ends of the anterior and posterior sutures effectively pull each end of the graft through the DALA cannula into position along the rim. An arthroscopic grasper and probe may be used to aid in positioning the graft, but typically, this is not necessary. Once the graft is provisionally placed along the rim adjacent to the native labrum, the anterior anchor sutures are retrieved via the MAP. The suture previously passed through the graft will be the post suture for tying. The corresponding suture strand is then looped around both the native labrum and graft by piercing through the chondrolabral junction, similarly to a labral repair, and tied using standard knot-tying techniques, securing the anterior end of the graft. Via the DALA portal, the posterior sutures are retrieved, and the posterior end is secured in a similar fashion. Once the ends of the graft are secured to both bone and the native labrum, the midbody sutures are retrieved sequentially, looped around both the labrum and graft, and tied using a standard technique to secure the augmented labral graft into place. After fixation of the graft, traction is released, and a dynamic examination is performed to verify that the augmentation is stable, the impingement is adequately decompressed, and the suction seal is restored. To complete the procedure, the anterior portion of the capsule is closed per a standard technique.
Kite technique for efficient graft management and fixation during arthroscopic hip labral augmentation shown in a left hip in the supine position. With the operative leg placed under traction, a standard diagnostic arthroscopy is performed via the proximal anterolateral portal (ALP) and the midanterior portal (MAP). After a standard hip arthroscopy, the hip is positioned into traction to allow for access to the central compartment. With the arthroscope placed within the ALP, a full assessment of the labrum is completed, assessing for pathology of the native labral tissue. When we elect to perform a labral augmentation, the labrum is typically hypoplastic, with a width of 2 to 4 mm, a poor native suction seal, and an intact chondrolabral junction. The region of labral hypoplasia is often segmental and rarely involves the entirety of the labrum, and therefore, a segmental augmentation is performed. During assessment of the labrum, an absent suction seal is identified. With a large adjustable cannula (Pivot TransPort 789 cannula, 110-140 mm; Stryker) inserted into the distal anterolateral accessory (DALA) portal, suture anchors (1.4-mm NanoTack anchors) are sequentially placed approximately 8 mm apart along the acetabular rim, just proximal to the hypoplastic labrum. Care should be taken to avoid perforating the articular cartilage. Ideally, the drill guide should push directly against the capsular side of the native labrum to ensure appropriate graft placement and restoration of the suction seal. The anchor sutures are organized with the anterior anchor sutures stored in the midanterior portal, midbody sutures within the accessory proximal midanterior portal, and posterior anchor sutures within the ALP, adjacent to the arthroscope. One suture strand from the anterior and posterior anchors is then retrieved via the DALA cannula for the kite measurement technique. The sutures within the DALA cannula are tied together, leaving a 1- to 2-cm suture tail, and hash marks with 5-mm increments are placed along the posterior strand, starting from the knot and spanning the length of labral hypoplasia. The knot is then transferred into the joint and placed directly over the anterior anchor. A suture bridge is formed between the 2 end anchors using a probe, allowing for accurate and reproducible measurement for graft preparation. A labral graft is then prepared using tibialis anterior allograft as previously described. One suture strand from the anterior- and posterior-most anchors is retrieved from the DALA cannula. A free needle is then used to pierce these sutures into their respective ends of the graft. Multiple half-hitches are thrown to create a knot onto each respective suture strand, leaving a tail of approximately 1 cm. The tails of each suture strand are colored to allow for easy identification once the graft is placed into the joint. At this time, the graft is inserted into the joint using the kite technique. The 2 end-anchor corresponding sutures, 1 out of the MAP and 1 out of the ALP, are sequentially tensioned, similarly to fly lines on a kite, and the knots on the ends of the anterior and posterior sutures effectively pull each end of the graft through the DALA cannula into position along the rim. An arthroscopic grasper and probe may be used to aid in positioning the graft, but typically, this is not necessary. Once the graft is provisionally placed along the rim adjacent to the native labrum, the anterior anchor sutures are retrieved via the MAP. The suture previously passed through the graft will be the post suture for tying. The corresponding suture strand is then looped around both the native labrum and graft by piercing through the chondrolabral junction, similarly to a labral repair, and tied using standard knot-tying techniques, securing the anterior end of the graft. Via the DALA portal, the posterior sutures are retrieved, and the posterior end is secured in a similar fashion. Once the ends of the graft are secured to both bone and the native labrum, the midbody sutures are retrieved sequentially, looped around both the labrum and graft, and tied using a standard technique to secure the augmented labral graft into place. After fixation of the graft, traction is released, and a dynamic examination is performed to verify that the augmentation is stable, the impingement is adequately decompressed, and the suction seal is restored. To complete the procedure, the anterior portion of the capsule is closed per a standard technique.