Hüfte

Geknotete Fadenanker

Die Produktreihe der Arthrex Fadenanker für die Hüftarthroskopie bietet umfassende Optionen zur Anwendung bei arthroskopischen und offenen Labrumrefixierungen und -rekonstruktionen. Die SutureTak®-Produktreihe bietet Versionen mit unterschied- lichen Außendurchmessern und Materialien, wie bioabsorbierbares PLDLA, BioComposite und nicht-resorbierbares PEEK.

Product

FiberTak-Soft-Anker für die Hüfte sind jeweils mit verschiedenen innovativen Fadenoptionen einzeln und doppelt geladen verfügbar. Die Anker werden durch gebogene und gerade Applikationssysteme sowie Bohrer mit 1.6, 1.7 und 1.8 mm Durchmesser ergänzt, damit möglichst wenig Knochen abgetragen werden muss.
Diese Anker bieten die Vorteile, klinische Erfahrung und die Produktunterstützung von Arthrex, die Operateure zu schätzen gelernt haben.

John Christoforetti, MD, (Allen, TX) performs a knotted acetabular labral repair using a curved 1.6 mm Hip FiberTak® anchor and a knotless acetabular labral repair using 2.4 mm Mini Hip PushLock® anchors, both with SutureTape. He outlines the steps for passing both simple and mattress suture configurations using the SwiftStitch™ suture passer to create a low-profile repair construct.

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Knotted and Knotless Acetabular Labral Repair Featuring 2.4 mm Mini Hip PushLock® Anchors and 1.6 mm Curved Hip FiberTak® Anchors

The first anchor we're going to place is going to be focusing on the far anterior position. We're utilizing a curved drill guide in this position for a standard FiberTak that will be used for a knotted repair. We utilize the flat portion of the external drill guide to cue us towards a drill angle position that angles slightly anteriorly and slightly superficially to avoid both penetration into the articular surface, as well as any penetration into the deep psoas canal. We visualized throughout the course of the drilling, the articular surface. As we drill, we try to sound the canal to be certain where within the bone. Next, we take a night in a wire, and we sound the bottom of the canal to assess for any errant penetration into the soft tissues, feeling a good anchored bottom. Stop. Now in utilizing a 50 yard line view where we have the labrum in the center of our field, we can see both the drill guide as well as the articular surface while we deploy our anchor. Next, we push this in by hand to avoid any angulation changes. To set the anchor, we grab the plastic handle and withdraw slightly. We've now set the sutures. We undo the black tab and we withdraw the central handle protruding. We can see the suture ends and we tug to test security. First I'll grasp the SutureTape, leaving approximately a centimeter of distance so that I have enough slack. And we're going to be placing a simple suture. Penetrating smoothly through the separation point of the labral base, we depress. Withdrawing the sheath. A gentle twist. List. And now for facilitation of Not passage, we can either utilize the same passing device or a standard ring Grasper with its smooth edges to be certain to protect our suture. Having made such a small penetration point with the appropriate passage device. One of the main advantages of modern hip arthroscopy is that we have multiple variations for anchors and guides, each specific for which region of the acetabulum we want to access. In the intervening region between the far anterior or 3:00 position or below, and the 12:00 position we previously identified, we have the greatest acetabular bone stock for placement into the ilium. In this position, we'll be using labral based refixation to use the short 2.4mm PushLock, allowing a knotless security because we have the best access for visualization. Notice that we've preserved the proximal flap of capsule for later repair, and we have excellent visualization without iatrogenic damage to the femoral head. When we use our bird's eye view to select where our next anchor will be, we might select between 5 and 10mm to place one anchor, and then an additional anchor. For our far lateral positions. We can start to utilize the curved drill guide again. Now for drilling for the 2.4mm PushLock anchor. Using the straight guide through the distal anterolateral accessory portal, we want to drill viewing the articular surface. We want to use the nitinol wire to tap and make certain that we feel good bone at the bottom of our tunnel. This will also clear any intermittent debris. Using the bird's eye view position, we can identify our far anterior anchor, followed by our initial knotless anchor at approximately the 130 to 2:00 position. And now we move up to the 12:00 to 1230 position, and we drill our second anchor in the knotless fashion for an overall three anchor repair centered around the far anterior. So as you position. Using the nitinol wire to verify that there's a good bottom and no penetration of either the depth of bone or the articular acetabulum, we place the suture between the rim of the acetabulum and the labral base tissue. We can release that suture. We return to the labral base position, making sure that we're not incarcerating the suture, verifying that we're radially away from the drill hole, meaning directly across from the drill hole penetrating the base labral tissue, as described by Ben Dohm. Deploying our device safely. Capturing the suture end. Withdrawing through our ultimate suture placement tunnel. Following placement with the SwiftStitch. We'll have an assistant or a Or a suture grasping device. Secure the limb of the suture that exits the ultimate placement portal, which in this case is the distal anterolateral portal. We'll grasp the placement limb and then feeding the short two four PushLock. We're ready to complete the knotless repair in a simple fashion. Externally, once we've passed and secured our suture. I tend to use a hemostat, at least until the point that we're certain that our PushLock has been capable of going all the way in, and really is in a good position at that point. We know that we really don't need the hemostat any longer. But in rare cases it may be helpful, particularly if working with new assistants. Now, as we place our PushLock against the bony rim, we have an opportunity to assess our inversion. Inversion. And we usually simply place this in by hand watching that labrum draw into position. And we really want to try to assess have we everted the labrum in any way. And in this case it looks like we haven't. We then view the articular acetabular surface. Our first deployment step with the PushLock is typically to make a light couple of taps on the handle itself before removing the deployment guard. In order to be certain we've seated this fully. Next, we remove the deployment guard. Mailed into place. Listening for the pitch change. Right there. And using the laser line as our visual cue. What we'll typically do is open this device towards the stitches. Make sure that we can see and visualize those all the way down to the bony rim. And we can trim. What we've done now is switch our camera to our mid anterior portal or distal anterolateral portal, whichever you prefer. And we've moved our TRIM-IT cannula into the contralateral portal for placement, utilizing the curved guide of a more posterolateral suture anchor. As we view the articular surface, and we view the outer table of what's becoming the posterior aspect of the ilium into the posterior wall, we use that curved guide to avoid both exit into the space posterior to the acetabulum, where the sciatic nerve exists, as well as penetration avoidance into the articular acetabulum. Next, we need to engage and set by pinching both the suture and the handle and drawing back. Once we've hit the end of its excursion, we remove the black tab and then we withdraw the handle and we checked the security of the knot, which is excellent. At this point, we're going to demonstrate a labral base stitch utilizing a knotted repair construct. First we take our hemostat and as at our previous step, and always with knotted repairs, we want to identify that there is some free excursion of the suture. To enable the passage of the stitch, we select which tail that we may want to use as our post limb. Next, we're capable of approaching verifying which limb that we've identified as our post capturing our alternate limb. The difference between a simple and a base suture using the knotted repair isn't in the first pass, but in the second. At the first pass, we're simply going to the to the chondrolabral base is typical and demonstrated at our anterior most anchor. We're now going to penetrate into the acetabulum. Deploying our suture. Next we withdraw and at this point we need to penetrate the labral base tissue itself, capturing the same limb to facilitate this in a safe passage manner, preserving the integrity of the stitch. First, we'll regrab the suture and increase the amount of suture within the acetabulum. Next, we'll penetrate the labral base tissue itself. Recapturing the same limb of suture previously passed, drawing back through the labral tissue. We place the FiberTak, we've utilized the labral base refixation suture pattern with two PushLock centrally, one with a simple pattern, one with a labral base pattern, and far anteriorly a FiberTak with a simple pattern. And now we can reduce the hip. To assess the suction seal of the labor repair. Noticing that even in the superior most placed anchors, even at the 12:00 anchor where we placed a simple suture, we have a beautiful seal at our labral base. Suture locations. We have a free edge of labrum with good seal. Our capsule is preserved for anatomic repair and posteriorly are not. Stack is nowhere near the interface between the femoral head and the acetabulum.

This animation features 1.6 Hip FiberTak® soft anchors being used with a SwiftStitch™ suture passer for an acetabular labral repair.

Hip Labral Repair Using the 1.6 Hip FiberTak® Soft Anchor

Hip labral repair with hip FiberTak anchor labral base stitch. Use a retractable hood bur to complete an acetabular plasty and prepare the rim for anchor placement. Place a 20 degree curved drill guide on the acetabular rim, and use a flexible drill pin to create a pilot hole for anchor insertion. Insert an awl suture FiberTak anchor through the drill guide and impact the handle by hand to a positive stop initially. Set the anchor in bone by grasping the sutures and pulling the handle proximally. Remove the handle and pull all of the sutures to confirm the anchor is adequately set in bone. Remove the drill guide from the cannula and advance the SwiftStitch suture. Passer down the cannula. Load the Bio-Post limb of the SutureTape into the SwiftStitch suture. Passer and pass it through the controllable junction. Remove the suture passer and repass it through the mid substance of the labrum to retrieve the previously placed suture. Tie an arthroscopic nut and insert subsequent anchors as needed.

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Acetabular Labral Repair With the Hip FiberTak® Anchor

John J. Christoforetti, MD (Allen, TX), shares technical pearls for inserting anchors into the acetabulum using curved and straight guides. He also discusses safe joint access when beginning hip arthroscopy procedures. In this cadaveric and sawbones demonstration, Dr. Christoforetti reviews the appropriate use of the curved anchor delivery system during acetabular labral repair and details a unique method for entering the hip joint with minimal damage to surrounding anatomy during periportal capsulotomies.

Safe Hip Joint Access and Anchor Placement Considerations and Technical Pearls

So we've already made an anterior lateral portal in this cadaver specimen. You have a way here to try to minimize the trauma associated with your portal creation. We're making a second, more anterior portal. And as we create that portal, we can see on the external side of the capsule, deep in our arthroscopic field, the pressure of the needle tip against the capsule. I simply readjust and find the right way into the hip joint. Capsule. We pass the nitinol wire down. We'll hold the very posterior end of the nitinol wire, and our assistant will remove the needle. And we regrasp the wire. What we'll typically do is take the interior sheath down without its external cannula. We always want to visualize the tip of that nitinol wire, so it's not driven into the socket itself. And we're going to going to go see this straight down onto the capsule. And we can use two fingers to feel the trampoline style bounce back of the capsule. Then we just make a half moon arc of twist that helps us to dilate a pathway, gently making sure that there's no undue pressure to dilate our way in. We can see ourselves about to emerge into the joint back out of the joint. And at this point, we've dilated. Now we'll typically do that serially with a 4.0 and then or the 4.5mm, then the 5.0. Then we take the closed cannula, make sure that we're screwed in tightly. We then go down over seeing again on the arthroscopic view the tip of the wire. We go down with a twisting fashion. No excessive pressure, with a twisting fashion right down to the entrance of the capsule. Then, rather than take the metal sheath in, we remove the center and we remove the nitinol wire. At this step, we use the straight blade to come straight down the cannula and enters directly at the capsule or entry point that we've pre dilated. At this position, we're now able to very carefully open the capsule without trauma to the labrum or the femoral head by the outer sheath of the cannula. Now this is what we're terming a periportal not inter portal but periportal capsulotomy that goes full thickness from the capsule superficial surface into the joint itself opens mobility for the portal. And at this point, we're capable of recanting the closed cannula and safely and gently screwing the cannula in for an appropriate switch of the camera to view the blind portal created without the assistance of arthroscopic localization. And we can see that our blind portal had also been created without labral penetration. So at this point, you can visualize that the metal cannula itself has very limited mobility inside a blind portal, because we were not able to create this with a capsulotomy first. Now, as I draw back by gentle twisting motion, just to feel the exit of the metal cannula from the capsule, leaving the blade itself inside the joint, I can make an easy full thickness periportal capsulotomy surrounding my anterolateral portal as well. And this will allow easy passage of the cannula without excessive pressure of the cannula tip against the cartilage surfaces. So we're going to talk about now are some concepts and principles of safety for drilling into the acetabulum as we get into multi-angle drilling devices and procedures. What's important for surgeons to understand is the orientation of the acetabulum. And each individual patient looking at this side on view against the model of the cadaver hip, we can imagine the same type of view could be achieved by bringing a three dimensional model into the surgeons operating room. Using that model and trying to set using the anterior superior iliac spine on both the model as well as the cadaver to help orient the ideas in the brain of where are the ilium, ischium, and pubic bone stocks of the acetabulum as you're approaching. In addition, looking at the differences between straight and curved drill guides. There are consequences as to which main bone stock are being accessed for the depth of drilling beyond the tip of the guide that is required into that between one and a half and 2.5cm distant, or distal to the tip of the guide. When you look into the far posterior positions and posterior anchors, where safety bordering the sciatic nerve posteriorly is an issue. Angling the curved device or straight device away from the articular surface will result in penetrance posteriorly in these particular areas, utilizing a Utilizing a posterolateral drilling angle approach. Turning the curve of that device towards the posterior wall will help access the ischium bone stock anteriorly within the acetabulum at the psoas you or 3:00 position. Finding that low, flat angle to avoid penetration of the articular surface can result in very little bone on the inner table, and often depth of drilling will penetrate back on the inner canal of the psoas and lead to irritation and the need for explantation of those devices. So curving that guide away from the penetration danger points and towards the main body of the pubic bone will allow an angle of approach that creates a safer approach for these low anterior anchors. These have traditionally been the most difficult anchors. As a straight guide, coming even low and flat can have a difficult time with the soft tissues and the angle of approach with the with the trochanter achieving the appropriate angle to make a low anterior. Drill approach. Understanding the trajectory of the curve. Is critically important to allow access to drill an appropriate depth drill hole into the main body of the pubic bone. There are cues to mark that there is a laser line, as well as a flat area to the handle. That allow the surgeon to feel the direction of the concavity of the drill, such that from outside the skin you can feel, as. In this position, my thumb is resting on the flat area, and we know that that means the drill is curving towards this area in the 70 degree lens. Just like in this video lens, it can be difficult to perceive the actual angle as the camera here is focusing on what is a curved drill, but appears in two dimensions to be straight until we really bring it into profile. And now we can see that. So utilization of the laser line as well as the external ergonomic flat handle are critically important to avoid positioning and then needing to reposition or not understanding exactly where that's going. And a rule of thumb might be to visualize the psoas you arthroscopically with the camera and the anterolateral portal viewing up towards this area. We'll see this as a U-shaped construct, and we're just going to turn that model to show that you here we can see in the camera projection the U. Of the so is U. And that is more typical of what arthroscopically we're going to be seeing, which will just look like a dip away into the 3:00 position and down below utilization of the thumb against the flat portion of the handle, and recognizing that the thumb itself should be down towards the patient's leg in order to really access the appropriate drill angle if that flat portion is towards the ceiling in a typical supine position. One can see that that's going to result in a drill penetrance at a high likelihood. So you have different ways to use that ergonomics. Now if we place that angle and use our thumb towards the patient's foot, we're now at minimum we're going to be drilling into safer pubic bone stock. We'll use the straight guide to demonstrate that. Now that's quite different from the use of the straight handled guide, which in all dimensions on the camera is going to be straight because it is straight. And as we access that area, the traditional difficulty in this zone has been trying to angle one's hand enough at the same time as one is trying to image from the same direction to see what they're doing. And all of the soft tissue interference has made it a problem. So now you can see how you can best from outside and inside, use the curve to access far anterior areas of the pelvis.

Michael Huang, MD, (Colorado Springs, CO) demonstrates an acetabular labral reconstruction technique using tensionable BioComposite Knotless Hip SutureTak® anchors. In this cadaveric demonstration, he outlines the novel pull-through technique with simplified graft passage, which minimizes the procedural steps required to achieve graft fixation.

Tensionable Acetabular Labral Reconstruction Featuring BioComposite Knotless SutureTak® Anchors and FiberTak® Soft Anchors

Today we're highlighting hip labral reconstruction. This is a right hip specimen, and I'm currently in the anterolateral portal. We've done some prep work already to make it a little bit smoother and faster. This is a probe coming through the mid anterior portal. And so as you can tell, the specimen's been prepared. We've done some acetabular work here already in preparation for the labral reconstruction. There's the rest of the acetabulum. Femoral head down into the foveal area. Immediately we put in a FiberTak anchor. And this is a fairly low position for us. So we're going to use the curved guide. The laser mark tells us which way the curve is going. So we're going to push this right down to bone. And we're going to go ahead and ahead and drill while we're viewing Intra-articular. Make sure it doesn't penetrate. I'm going to tug on that to make sure it's in. Usually I put the anchors in without a cannula. We had done some prep work on this to make sure we had everything ready. So I'm just I'm removing it mostly to simulate what we do normally. So normally I place these anchors without the cannula in place, and I put the cannula back in when we're passing the graft. And so what we're doing exterior here is we've got several hemostats ready that are labeled. Since I put the anchors in from medial to lateral. This is just by convention, the number one anchor for me. Now we're going to highlight the Knotless SutureTak three zero composite. This is a hip length anchor. This first Knotless SutureTak anchor is placed very close to the FiberTak anchor In order to achieve excellent graph compression at the far medial location, and this is going to be a knotless anchor. So. Good. We have some other portals already made in preparation. One is the posterior lateral portal which we have here. Standard location. We have a seven by nine cannula over here, sometimes at seven by 11 depending on the patient body habitus. And then this spinal needle, which hasn't made it all the way into the joint, is going to be a fourth portal for suture management. And we'll show you that in one second. Good. So I'm placing FiberTak in this location in hopes that, as the last suture, it will not only be able to incorporate the graft, but also potentially serve to re approximate the residual native labrum to the graft. We we prefer to use manual pressure when we first advance the FiberTak into the pilot hole, and then we mallet it in using the palm of our hand. That seems to be a very reproducible technique to deploy the anchor. Okay, so now we've switched back to the anterolateral portal. Here's the first anchor. It was a double loaded FiberTak. Next is the Knotless three SutureTak biocomposite. Same thing here. Same thing here. Same thing there. And then the final anastomosis stitch is another FiberTak there. So there's the round the world shot for you. And we're going to create this fourth portal here where we have the spinal needle place. This is for suture management. So I'm going to go ahead and push that into the joint. Now there it is. And we're going to dilate that up. So we'll have the thin guidewire. This portal is approximately halfway between the anterolateral and mid anterior. This this portal can be moved more approximately if you want to shuttle all the sutures proximally. Or it can also be the the traditional dollar portal as well, if that's where the anchors were placed. What we have here is we have all the all the sutures that were placed in order. Each one has its own snap. For instance, this is number four here. And then they're placed. They're still docked out where we placed the anchors. So the reason for this fourth portal is we want to transfer all of these through this portal so that when we pass the graft, it's all clean. So you're going to see us go through this portal with the CrabClaw loop Grasper. And we're going to be shuttling these stitches out in sequence. So we have the loop grasper through that fourth portal. We're heading over towards the number one FiberTaks the double loaded FiberTak anchor. We've got all four limbs. They've unsnapped it externally and we just want to maintain our portal. So we're just going to have the sled again, and we'll just be going back and forth. And there they are. So we'll take those out and then we'll resnap it on this side. So again just for suture management it's nice and clean. And then we'll just do that again for the next one. So these are the three limbs from the knotless SutureTak. The blue is the shuttling suture. And then the striped is the main suture. Okay. So we'll snap that. Okay. So at this point we've shuttled all the suture limbs out of this fourth portal. You can see that on the external view. And now we're not going to place the TRIM-IT cannula medially here. So that's where the graft will come in. And then the graft will pass across the femoral head to the posterior lateral portal. Here I've left the last FiberTak anchor here outside the same cannula that I placed it just for convenience purposes. So okay. So now for again suture management. What's going to happen is the graft is going to come through the TRIM-IT cannula through the mid anterior portal and pass all the way across the femoral head like we discussed to the posterior lateral portal which is here there. And then once the graft is all the way out, then we are going to use one of the limbs of the FiberTak first anchor to place the medial border of the graft. So this technique allows us to avoid having any length mismatch with the graft. We want to be able to use as much or as little of the graft as we want. So in order to shuttle it back medially I'm going to take the blue stitches from the first FiberTak. An alternative way to perform the reconstruction is to split the sutures and pass the graft in between the sutures. So what I mean by that is we are going to place the main suture, the blue and white striped suture from the knotless suture tax on the femoral side, keeping the suture shuttle solid blue, suture on the capsular side or the acetabular side. And then we're going to shuttle the graft all the way across. The reason for that is it can be very much a time saving method where if you do that, then the main suture is already passed for you. And once you've accomplished that, then all you have to do is finish the suture shuttling. So again this is the main suture limb for the knotless SutureTak. And I'm just going to push it down creating an opening for the graft to go through. Meanwhile we're keeping the suture shuttle for the knotless SutureTak on the on the acetabular side. So we're just doing that for each anchor right now. Okay. So see this window here between the shuttling sutures and the main suture. That's where the graft is going to go. So what we need to do is bring the shuttling suture for our graft from the posterolateral portal across this here's this shuttling suture here. There we go. So now we have it. So this is the hip labral Scorpion. We're going to load it with one of the limbs of the FiberTak. And then we've got our prepared graft. This has been prepared. So whether or not you're using fascia Lata or Tib and or gracilis or whatever graft you're using, the the lateral end is whipstitch here, traditional fashion, just so we have control over it. And then I've simulated a tubular ization type of stitch. This typically would be two of for me using a fascia Lata allograft. But this allows The SutureTape to not pull through at the end of the graft. So we're going to load the SutureTape on this end, because this will be the medial side, and then it'll come across the acetabulum, and then all this will be extra, but it will come out the posterolateral portal. So again we're not measuring. We don't need to worry about any graft length mismatch. So usually this graft is very thick. So we're just using the Scorpion to help us pass it through here. And we're just going to tie the SutureTape onto the graft. Yeah. So we passed the limb through the tail end of the graft and then made a cerclage loop around it and tied it to itself. So now we have firm fixation with that limb of SutureTape. And then the opposite limb here will let us advance it into the cannula. So now we're going to pass the graft using that suture shuttle. I'm going to place the lateral tails of the graft. And we're going to start shuttling. So the TigerWire. Here is the suture shuttle and then the blue is on the graft. So we're just going to get that out the posterolateral portal. And we're going to get it to the TRIM-IT. And then I'll use the KingFisher to just get the graft into the cannula. So now the graft is coming in. Yeah I like to keep this switching stick in the fourth portal to help us manipulate the suture tunnel, if you will. So you can see what can happen here. You can see the graft going in the suture tunnel from mid anterior portal to the posterior lateral. And we're going to keep pulling it until we see the medial border of the graft, which will be signaled by our blue SutureTape. So now we just have to pull on the correct limb of the SutureTape to advance the edge to the anchor. Okay. So here we are. We're at the very far medial side of it. The graft hasn't been totally advanced to the first anchor yet, but it's about to be. And then here's the main suture for the first knotless SutureTak, which was our second anchor that we placed. And so now if you take a look, the main sutures for the knotless SutureTak are already on the appropriate side of the graft. So here's number two. Here's number three. Here's number four. And there's number five. So we're already set up for success here. So once we finished securing the medial border we'll sequentially secure those. We're using a knot pusher to secure the medial anchor. This is again the double loaded FiberTak. We have secured it to the limb of the graft. And this is the. The post is the side that we use to advance the graft to the anchor. So we're just going to use some alternating half hitches here. So now what's left is the second suture from the original FiberTak. In this case I think what I'm going to do is go ahead and secure the first knotless. So that's going to be number two. So I'll have my assistants unlock number two. And we're going to go ahead and feed them through the mid anterior portal because that's the direction that we place the anchor. So I like to always secure the knotless suture anchors if I can, in the same direction that they were placed. All. Right. We're doing the normal SutureTak knotless mechanism. We've got about half of the white trail thread through the loop side, and now we're going to advance that. And then I like to put in a loop grasper. So we can somewhat manipulate the graph to the position we want it. So let's say we like it right about there. So now we can use we can use the loop grasper to either control the graft or the loop. In this case I like the where the loop is. There it goes. And again, because of the tension aspect of the knotless, we don't have to get this totally down, but this is looking really good. So I'm going to go ahead and tighten it a little bit more like that. And we'll come back and we're going to leave those long and come back and retention. So then we rinse and repeat. And so for the surgeons that want to tension the graft even more, what is available now is you have control over the lateral portion of the graft through the posterolateral portal down here. So a lot of times I'll be placing a little bit of tension here while asking tension on the on the anchor itself. Or you can use the graft holder and then tighten that down a little bit more and just kind of pull it a little bit so you can see. Perfect. Okay. So we're kind of provisional right now. We kind of like everything first anchor the most medial. And for laboratory demonstration we just went ahead and used the one suture and unloaded the second. And then here's the first knotless SutureTak the second, which we will still come back and revisit to do final tensioning. So again First suture anchor. First Knotless. Second Knotless. Third Knotless. You can see the nice apposition of the graft to the Chondral junction. Okay, we're going to switch portals and then finish up our fixation from the other side. Okay. We're viewing from the mid anterior portal. We've brought in the Apollo h50. We're just using it to clean up a little bit of the fraying around the graft in a controlled fashion, just to improve visualization a little bit. Yeah. This probe allows me to use the edge, which is a 360 degree, even without touching the the graft itself, we can just use it to contour the tissue. And this really helps visualization. Here is the main suture for anchor number five. And then these are its shuttling limbs. So we're going to grab all those out the same soft tissue windows. Okay. So we got a little I got my hand on the graft at the posterolateral portal putting a little tension on attention on that. And then my other hand is just going to tension down this last suture, last knotless suture anchor. I should say we can back up the cannula now. Okay. So we've got the last FiberTak here. This SutureTape on the FiberTak. We're just tying this down, and I get the last point of fixation on the far posterior side. And we're going to walk that right to the acetabular rim. And there it is okay. There we go. So we're going to do our final tensioning on the Knotless SutureTak, which is one of the features I love about this anchor. We can selectively tension that one okay. We're loading the suture tensioner cutter. And when we're ready we'll just use the cutting mechanism. That's it. Now that the graft is fixed we're going to truncate the graft. We don't need any more. This is again why this technique the pull through technique is so valuable. We don't have to worry about length mismatch. I usually use the Apollo for this. This is the part of the graph that was shuttled through the joint but was not used. So again, one of the benefits of the pull through technique is that there's no need for measurement or inaccuracies on that end. So okay, we're going to switch portals and just finish up the final tensioning and cutting. So here's our reconstruction now. Medial central. And there it is. Traction is off. And we're trying to simulate a flexion on this cadaver. As you can see we have a very nice recreation of the labral seal. We can do a little bit of rotation. Maybe there's the knotless anchors and trying to show you medially. There you go. And laterally. There it is. So there's our final construct.

FiberTak®-Softanker für die Hüfte

Child (D)

Der SutureTak ist ein bioresorbierbarer oder nicht-resorbierbarer Fadenanker aus PLDLA, PEEK oder einem BioComposite-Material aus PLDLA und β-TCP. Das spezielle angeformte Fadenöhr verhindert Fadenabrieb beim Knoten und richtet die Fadenenden bei der Einführung so aus, dass der Faden optimal gleitet. Das einfache Vorbohren mit einem Bohrer über eine Bohrlehre, die im Verbrauchsartikelset enthalten ist, und das Einschlagen mit dem Hammer reduzieren die Operationszeit erheblich und schonen den Knochen. Jeder Bio-SutureTak ist mit einem hochfesten einfarbigen FiberWire® der Stärke #2 und/oder einem gestreiften TigerWire® der Stärke #2 vorgeladen, die das Nahtmanagement und Schenkelerkennung beim Fadendurchzug und Knoten erleichtern. FiberWire-Fäden sind zug- und reißfester und weisen eine bessere Abrieb- und Dehnungsfestigkeit auf als andere hochfeste Fäden.

Brian D. Giordano, MD, (Rochester, NY) demonstrates an acetabular labral repair using a variety of suture anchors. In this video, Dr. Giordano passes multiple suture configurations using a 2.0 mm Mini Hip SutureTak® anchor, a 2.4 mm Mini Hip PushLock® anchor, and a 3.0 mm Knotless SutureTak anchor.

Acetabular Labral Repair

So this is Brian Giordano. I'm going to be performing arthroscopic acetabular labrum repair. What you're seeing here is total working length of the SwiftStitch. My thumb is going to depress the thumb piece. There's a nice ergonomic feel to the device. Suture can then be grasped or secured at the tip of the SwiftStitch pressure is applied to the thumb piece. Thumb piece is then slid back into position. The suture is nice and secure, and once the suture is is passed, the thumb piece can be depressed, advanced, and the suture will be released for later retrieval using a distal accessory portal. This facilitates a very anatomic perpendicular positioning to the acetabular rim to avoid iatrogenic intra-articular anchor placement or drilling. After I place the 14 gauge needle, I'm going to place a nitinol wire. Through the cannulated portion of the needle, I'm going to withdraw the needle, leaving the nitinol wire in place. Now the Now the nitinol wire is positioned in the joint, and we're going to be introducing a plastic cannulated obturator over the nitinol wire with Drill Guide. So you can see the plastic cannulated obturator advancing into the joint over the nitinol wire. The nitinol wire is then withdrawn. Plastic obturator is then withdrawn. So there are two really nice points of orientation on this guide. One that there's a laser line which corresponds to the the angulation of the curved guide. Secondly, the handpiece of the guide has a flattened portion that corresponds to both the laser line and the upswept portion of the guide. So this allows the guide to be placed in very tight proximity to the labral control interface, so that you can technically be as perpendicular as possible to the acetabular rim resection I'm going to be viewing in the joint as we as we drill, ensuring that there's no accidental intra-articular penetration of the drill. So we're using a two PowerPick SutureTak anchor with a positive stop. This has number one FiberWire SutureTak, which is a nice low profile suture configuration. So you can see that the anchor countersink so that it's deep to the drill tunnel. The guide is then withdrawn. So once the anchor has been placed, one thing that's important is to actually toggle the suture through the eyelet of the anchor to make sure the the suture slides easily. And that will help to facilitate suture passage and retrieval. Next the SwiftStitch is introduced into the joint. And in this case the suture is retrieved a little bit higher up. And what that allows is, is a relatively tension free passage so that there's enough redundant suture material. And I and I assess that both from the intra-articular and intra-articular side that's passing very nice atraumatic manner with as minimal a footprint as possible. The suture is then is then released. Swiftstitch is then passed either around or through the labrum, depending on surgeon preference. Suture is grasped and withdrawn from the joint. I'm going to retrieve the other suture limb with a CrabClaw suture grasper. And then I'm going to tie on the extra articular portion of the joint. At the end of our repair we have a nice knotted construct. It's perpendicular to the orientation of the labrum. It's far anterior toward the psoas notch and very, very thin low margin of error bone not as low profile and with very minimal trauma to the to the labral interface. For our next two anchor configurations, we're going to be using two four mini hip PushLock through a mid anterior portal. I'm going to change my position slightly, about one centimeter away from my initial anchor And with the guide in place, we're going to be introducing the drill. We're going to drill both both of our tunnels right away. And visualizing both intra and extracellular positions. Again I'm spacing myself approximately one one centimeter apart. Next I'm loading my SutureTape using my SwiftStitch. I'm going to be passing the limb of the suture first through the transitional zone at the RetroDrill interface. I'm then going to retrieve the suture in a mattress configuration through the labrum. Next. We're going to load our suture strands through the anchor. The anchor is going to be placed in our first tunnel. If you're slightly loose initially, the anchor should be placed adjacent to the bone. The orange outer protective cap will be removed. The inserter handle handle is withdrawn. The suture limbs are then cut using an open ended suture cutter. And as you can see, using the SwiftStitch, which has a 1.5mm tip, very minimal. There's very minimal trauma to the surface of the labrum. Next we're going to be passing a third suture. Again with the attempt to be perpendicular to the drilled tunnel. The stitch is again passed through the drill interface using the SwiftStitch with minimal trauma to the tissues to promote a tension free and anatomic repair. Once again, we're going to use a horizontal mattress configuration using the benefit of the 1.5mm tip of the SwiftStitch to penetrate the labrum and facilitate this technique for repair. So once again, you can see the two four mini hip PushLock anchor tip being advanced with the sutures slightly loose. The anchor is then advanced over the insertion handle. Orange protection cap is removed and the anchor is is tapped into place. It's. In a certain handle is removed and once again, an open ended suture cutter is passed over the over the sutures to cut them flush to bone. All right. So what you can see now in adjacent to the the initial looped anchor, we have 22. four millimeter mini hip PushLock anchors using a labral base or a mattress configuration. So now in this case, our our far superior posterior superior anchor has been placed through a distal accessory anterolateral portal. I've switched the scope over to my modified mini anterior portal, and I've switched my TRIM-IT cannula to my anterolateral trochanteric portal. So we're going to start out by grabbing the looped or shuttle suture portion of the knotless SutureTak. And that is the stitch that we're going to pass through our lateral control interface using our SwiftStitch. So the looped end, the shuttle suture of the knotless SutureTak is grasped with the SwiftStitch. And that is the initial suture that's going to be passed through the labral interface. Suture is then docked and it's retrieved. And secondarily a CrabClaw suture grasper is going to be used. To then retrieve the repair stitch. And of note, the repair stitch is visibly a different color, helping to differentiate the suture types. What you can see is the repair stitch being passed through the loop. I generally like to use an average distance where the color of the repair stitch transitions from from a white to a blue. That's ensures that adequate suture material will be retained once the suture is is passed and docked, but also ensures that the thinness of the suture is retained as it passes through the tip of the anchor. One of the advantages of using a knotless SutureTak anchor of this variety for this type of repair is that it is. It actually inverts rather than inverts the labral tissue, facilitating a more anatomic style of repair. One of the concerns during repair is that the that the labrum everts and is placed into a non anatomic position. In this case the labrum is actually inverted and the amount of tension can be varied. Using this technology to facilitate more or less tension or compression on the labor repair. At this portion, the tensioning suture still remains out the distal accessory portal. I'm going to retrieve that through the anterolateral portal, so that we can cut this flush to bone using the percutaneous tensioning cutting device. So now in terms of our final construct we have our our far anterior tool SutureTak far anterior with a looped and tied configuration. We then have 22.4 PushLock anchors in a horizontal mattress or a base configuration. And finally Posterosuperior. We once again have A30 knotless SutureTak in a looped configuration.

Geknotete Fadenanker

FiberTak^®-Softanker für die Hüfte

SutureTak^®