Die Arthrex Fadenanker für die Hüfte eignen sich besonders für die arthroskopische und offene Labrumrefixation und -rekonstruktion. Die PushLock®-Familie bietet Versionen mit unterschiedlichen Außendurchmessern und Materialien, wie bioabsorbierbares PLDLA, BioComposite und nicht-resorbierbares PEEK.

Der spannbare Knotless FiberTak®-Fadenanker für die Hüfte verbindet die Vorteile des Softankers mit einer knotenlosen Weichteilfixierung. Diese Anker sind mit geraden und gebogenen Zielinstrumenten kompatibel und der spannbare Fadenverschlussmechanismus ermöglicht Operateur:innen die Steuerung der Nahtspannung unter direkter Darstellung.

Asheesh Bedi, MD (Ann Arbor, MI), performs an acetabular labral repair using a Knotless 1.8 Hip FiberTak® anchor with a #2 machine-tapered suture.

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Acetabular Labral Repair Using a Knotless 1.8 Hip FiberTak® Anchor

Today we're going to demonstrate hip labral refixation using the new Knotless 1.8mm FiberTak. I want to share this anchor a little bit before we we show the technique some very nice features, new features of this anchor. The most important one to start with is this blue stitch here that you see, which is now a new machine tapered repair stitch as you use the FiberTak. The advantage of this is really much more resistant to fraying when you pass it, either with your labral Scorpion or your SwiftStitch. It's machine tapered as you move distally. The advantage of that also is when you go to convert this anchor through the knotless mechanism. It's a much more smooth and easy process to to perform that conversion. I also want to draw your attention here to the anchor itself. You can see the way this anchor is designed. You can see the prominence of that blue repair stitch, and the configuration of the anchor is slightly different. This offers a few advantages one. In terms of placement, it gives you a stronger pull out mechanism as it sits deep to the cortex on the acetabular side, and again creates some ease of conversion with this stitch. So we'll demonstrate those features and all the advantages of that anchor for label refixation. So if you look here, we're working on a right hip cadaver just to orient you. You're seeing that viewing from the proximal anterolateral portal that we've established here. Here is our direct anterior. And we've established a more typical conventional mid anterior portal. If you work more distally here, we can work from a distal anterolateral portal as well. For the sake of time here we've established approximately anterolateral portal. And here we've placed a TRIM-IT cannula to work through for our instrumentation of the labrum. Intra-articular here you can see. Here's our joint. There's the ligamentum. There's some arthritis in this cadaver, but there is working from our posterior to lateral labrum. And then there's the anterior and anterior-superior and anterior labrum. You can see here for the sake of time we've done a prep here of the rim. And we're now ready to place our anchor and then perform refixation of this labrum. Working from relatively anteriorly here out to more anterolaterally. So to demonstrate here, I'm one of the features and opportunities that you have with instrumentation. This is a curved guide for the knotless 1.8mm FiberTak. Some advantages here. To point out. You can see it has about a 21 degree curve. The advantage of this from the mid anterior portal is when we drop your hand and bring it like this, it effectively creates the trajectory of a distal anterolateral portal. That's advantageous to avoid intra-articular penetration when you're drilling, and really gives you a favorable trajectory with a two portal technique when you're working here anteriorly. A few other features here. You can see how it can become disorienting in the joint. To understand what is your curve. That laser line here demonstrates the direction of concavity. So that's the direction of 21 degrees cephalad or towards the acetabulum. That actually also lines up here with a flat portion on your guide that you're you're pointing here. So you know that those are aligned. So here we'll place that in that favorable trajectory here. Make sure that we're on the acetabulum. With our curved guide in place. We're ready to drill. The drill comes in there again. The curve is is set to our angle away from the acetabulum. If you're in hard acetabular bone, it's sometimes helpful to cycle the drill. That really helps for the FiberTak anchor to sit. So after drilling now we're sliding our 1.8 FiberTak down. This is a positive stop. You want to line up the flat portion of the anchor, with the flat portion of the guide there as it feeds down. You can see here it's a positive stop. Once you're there, you're you're ready. It's important now when you come back with your FiberTak to set the anchor, that you don't just come and jerk on these stitches. It's a gradual pullback. So we'll take out our guide here. So you can see that here's this gradual pullback. As you can see that sets the anchor nicely there. Now it's set deep to the rim of the acetabular cortex there. And now we're ready to go ahead and pass our sutures for repair. So just as an aside here outside of the joint you can see here this is the knotless FiberTak 1.8mm anchor. This is the repair stitch that we talked about. The blue machine taper stitch that is durable and less vulnerable to fraying. Showing you here. This is us loading it in the SwiftStitch. We usually load it a few millimeters away from the tip there, and then retract it in for passage to show you here nicely on the rest of the anchor. You can distinguish the repair mechanism from the tape. Those are machined differently. This is your other paired stitch that we'll use to pull to ultimately convert the anchor. And now we're ready to go ahead and pass through in a standard configuration. So here we are now inside the joint ready to go ahead and pass the repair stitch with the SwiftStitch. Here we're looking behind the labrum. There's the chondrolabral junction. There's a natural chondrolabral separation here in this particular case. So there's not much to poke through. But you would pass your SwiftStitch deep into the joint. Here's your repair stitch. You can release that repair stitch. And then the advantage of the SwiftStitch is you can come back in around the labrum and go ahead and grab that repair stitch with the SwiftStitch here. Here we'll grab the repair stitch and pull it back out. And then we're ready to create our knotless mechanism. So one one important step after you've retrieved the repair stitch is to run your repair stitch and the repair mechanism away to make sure you don't have any bridge. You can see here where you can you can distinguish the two. If you pull on the tape stitch the flatter of the two, that is the one you don't want. So you'll want to grab the round one here and separate it away from the tape one. And bring that together with your repair stitch. So here you can see when you're converting this anchor outside you'll want to bring in your machine tapered repair stitch through your loop on the machine tapered stitch. You'll actually see there's a purple mark. You can see it coming through right there. That's a good amount that you want to shuttle through right in that amount. And then you'll just hold that repair stitch together. The advantage here is you can see is none of that repair stitch is frayed. And this is tapered to allow it to shuttle through the knotless mechanism without a problem. So you can see here now with that loaded with the machine tapered stitch. You hold it here. And now you're set to go ahead and convert your knotless mechanism. You can feed that following right into the cannula. And again the advantage here of this machine taper is in the past this used to feel like it was sometimes a hard tug. But you can see that very smoothly loads through. And then now you have the have the ability to control your tension of your repair. So here you'll see me continuing to pull gently on that converted mechanism. This will continue to come up and around the labrum there and here I can continue to set that. I'm just going to roll our angle here. You can see it there. And this is always an important step with hip arthroscopy where you want to re fixate but you don't want to over tension and invert the labrum. Again an advantage here is we can even leave this repair stitch, come and continue to work around the remainder of the labrum and the rim, and then readjust our tension to assure we have a good suction seal when we come off of traction. So that's a nice mechanism. And I think you appreciated how easy that was to convert without vigorous and and difficult pulls. So here we are moving on to the second anchor. Now what you can appreciate here is these small anchors allow you to place them relatively close to one another, which is quite nice with the smaller anchor size. In this particular one, we're going to pass it in an inverted configuration using the Knotless mechanism. You'll see the advantage of that potentially in that rather than everting the labrum, it labrum, it actually inverts the labrum, potentially augmenting the suction seal. That might be particularly important in small or hypoplastic labrums, where you're concerned that your eversion can actually compromise the suction seal. Just as in the mechanism, before you want to gently pull back on these sutures, it's not a hard tug to set the anchor. You can see it's a gentle tug. You can do it even with your anchor guide there or off. And you can see now we're nicely placed there to pass our next suture. So here, when you're passing this in an inverted configuration, rather than passing the blue repair stitch, you're passing its paired stitch, not the tape stitch. And we're passing that through again, that chondrolabral junction here and delivering that into the joint just enough for us to be able to grab it here. There you can see that's passed with the SwiftStitch. So now that we've passed this loop, as you can see with the SwiftStitch in the inverted mechanism, you can come down with a post grasper. And this is a nice step where I can grab the repair stitch and the loop together in a single pass. And this allows me now to pull and retrieve and complete the step of assuring their shuttling together in the same setting. And that slides nicely that way to to now allow you to convert your your anchor. So as you can see here, the conversion of this anchor is just the same, whether you've passed it in the inverted or standard configuration. Here you're going to pass the machine tapered stitch right through the loop. You can bring it right back down here to this purple mark that you can see here folded there. And now you're ready to go ahead and convert your knotless mechanism in the anchor. We're ready to go ahead and shuttle that through the diaphragm. So I'll take the tape stitch. Let go there and watch the ease of this conversion here. As I'm pulling through. There's no jerking through the machine. Tapered stitch pulls through. And now this is in an inverted configuration. As we tension here I'm just going to rotate the camera so you guys can see that there. And interestingly as we pull this rather than inverting the labrum you notice it's inverting the labrum which is nice to go ahead and augment your suction seal as we're working around the rim here out to anterolateral. So as you can see here now we've completed that three anchor labor repair here. Starting there relatively anteriorly and medially. Inverted configuration standard configuration. And then here back to an inverted configuration. Achieving an excellent refixation even in this cadaveric labrum. If we wanted to continue here, you could work out and continue to work laterally and even posterolaterally along the rim with those small anchors. As you take down traction. You can even confirm your suction seal here. Again, that inverted configuration tends to push the labrum towards the joint. So you'll see here as you bring it in you usually need to bring it in and flex it up. We're going to keep loosening that traction here. You can see this maintenance of the suction seal here. With our labor repair working all the way from anteriorly there out anterolaterally there our most medial anchor here all the way out there.

Benjamin G. Domb, MD (Chicago, IL), demonstrates an acetabular labral augmentation using Knotless 1.8 Hip FiberTak® soft anchors. In this cadaveric demonstration, Dr. Domb outlines the steps for passing an allograft into the joint behind the native labrum and uses a SwiftStitch™ suture passer to pass the suture through the labrum and around the allograft tissue to recreate the suction seal of the hip joint.

Acetabular Labral Augmentation Using Knotless 1.8 Hip FiberTak® Soft Anchors

This is Benjamin Dome from the American Hip Institute in Chicago. Here today we are showing you a labral augmentation using the Knotless pull through technique. This takes advantage of a total of six knotless FiberTaks today, and the controlled tension technology allows us to preserve the native labrum and augment it with a tibialis anterior or tibialis posterior allograft, as you see in this short segment of video. So in this particular specimen, you can see that the labrum is still present and there are still circumferential fibers. But it is diminutive, especially anteriorly here where it's probably 2 or 3mm. And looking from a bird's eye view or capsular sided view, you can see there's only a limited amount of substance of labrum. So we'll preserve what is left of the labrum, but we'll augment it with a graft. So we've prepared the rim of the acetabulum by decorticating it to create a bleeding bed of bone for healing. And this goes all the way from posteriorly to about 10:00, all the way to anteriorly at about 4:00. And we can see down here anteriorly working under the iliopsoas in the 4:00 position. So we'll begin by placing an anchor at approximately the 4:00 position. So this is actually the iliopsoas notch. Bone becomes very thin anterior to it or medial to it. It becomes thicker again as you go into the pubic ramus. So here we are watching the articular surface while we drill to make sure that we don't penetrate the cartilage. We will sound the bottom of the of the drill holes to make sure it's a socket, and that there is an end and that it doesn't actually go out the iliopsoas fossa. So I can sound it with a guidewire like that, that's very important, so that we make sure the anchor is not protruding where we can't see it out, the iliopsoas fossa And rubbing against the iliopsoas. So that's our first anchor at the 4:00 position. And then we're going to move our way along the rim of the acetabulum. So at this point we have placed all of the anchors. You notice I placed the first anchor through the anterior portal. Then all the subsequent anchors through the distal lateral accessory portal. And if I were to go any more posterior than this, I would use the posterolateral portal to place more posterior anchors. And we can get all the way down to the transverse acetabular ligament, if needed, posteriorly and anteriorly, and do a true circumferential augmentation or reconstruction with this technique. So what we will do next at this point is we'll establish our posterolateral portal and introduce first a switching stick through the posterolateral portal. And then we'll follow that with a KingFisher. Now we'll place. We'll place the switching stick here anteriorly, anterior to the most anterior of the sutures. So as you can see in the overview here, we've prepped the graft. And on this end here we have reinforced the end with a FiberLoop and then tied off the FiberLoop. This reinforces the end to allow the knotless FiberTak repair stitch to slide through it without pulling through the graft. It's essentially a rip stop. And then on the other end of the graft here we have done a FiberLoop as well. And this will be used to pull the graft through the joint. So I'm pulling the first anchor from the dollar portal. I pulled out the repair stitch and the end of the stitch that has the loop on it. The end of the shuttle stitch that has the loop on it. So those are now coming out here. And then next I'm going to pass the graft itself. So we'll take the end of the graft here. That has the whip stitch, and we're going to pass this into the joint, and then we'll grab this here with the KingFisher, which is coming out the posterolateral portal, and start to pull it into the joint. And out the posterolateral portal. So we'll load our Keith needle with the repair stitch here. So what we'll do next is we'll pass the end of the repair stitch through the looped end of the shuttle. And we want to bring it to where the white ends meet one another, which is typically when the when the mark here is at the loop. So that's our that's our spot. We can pull the shuttle end out here of the dollar portal. And now we have our our end. And there it is. So, so we've now anchored the graft anteriorly at the very front of the of the joint at this point is when we're going to put in a cannula TRIM-IT cannula. So next we're going to begin to incorporate the graft and the labrum together. So we'll use the SwiftStitch here which is a suture passer. And we'll load just the end of the suture into the SwiftStitch. And we're going to bring the SwiftStitch down the cannula. And then right next to the anchor we're going to come through the labral junction. We can view this from The upper deck view here, where we're above the labrum to make sure that we're coming through the junction. And then here you can see we're coming through Chondrolabral junction from the articular side. Okay. So we drop that there and then we come on the distal side of the graft. Grab our stitch and pull it back out. And next we retrieve the round end of the shuttle suture. So notice that there's a flat end and a round end. I've got the round end here. And the round end is going to be the one that has the looped end of the shuttle. We're going to pass the repair stitch through the looped end and make it so that the white overlaps the white. And then we'll pull the end of the shuttle that's coming out the distal lateral accessory portal. We can watch from a bird's eye view, and if needed, we can just push the suture into the desired place. Okay. And now we tension the repair so that we roll the graft and the labrum together. And next we come through the Chondrolabral junction here. So we're around the labrum. Deliver the suture. Come from the distal side or articular side of the graft and fetch our suture. And next we'll retrieve our round end of the shuttle suture. Load this up once again. So so there's tensioning rolling the graft and the labrum. So here as we get ready to tension this last stitch, we can just observe one more time. Here it comes through the Chondrolabral junction. Goes around labrum, goes around graft and then is tensioned. So you can observe this from a bird's eye view as we tension and we wrap together labrum and graft. At this point we've completed the augmentation and we'll amputate the end of the graft, leaving enough graft there to overlap with the native labrum and enough that it doesn't come too near. Our final stitch there. So we've now pulled out the end of the graft that I amputated through the posterolateral portal. Here we can see the completed augmentation, and we've got an excellent seal all the way around. And the seal is accomplished by the combination of graft and labrum, which are bundled together, producing a great seal.

Travis Menge, MD (Grand Rapids, MI), demonstrates a novel way to invert the acetabular labrum during a labral repair procedure. In this cadaveric demonstration, the repair suture from a Knotless Hip FiberTak® soft anchor is passed through the labrum with a SwiftStitch™ suture passer to anatomically restore the suction seal of the hip joint.

Acetabular Labral Inversion Using the Knotless Hip FiberTak® Soft Anchor

My name is Doctor Travis Menge from Grand Rapids, Michigan, and today we're going to be doing a labral repair arthroscopically, and we're going to be using the 1.8mm Knotless FiberTak anchors in the hip doing an inversion stitch technique. As you can see, we're looking at a right hip. We're viewing posteriorly through the mid anterior portal, and we're working through the anterolateral portal. We've got our guide in place. And again we're right at that junction above the labrum. And what we're going to do is I typically will tap a couple gentle taps to set that guide. And as we drill, one tip that I found is really helpful, especially in patients with softer bone or young patients with really hard bone is after you drill the initial anchor site, you want to go in and out a few times to clear that spot of any bone debris. And that's really going to help that anchor deploy and have that strong fixation. Whether you have bone that's a little soft or very hard, and you want to make sure that anchor expands. And that's the problem. If you have bone, that's extremely hard is you can drill the tunnel, but if there's bone debris and the anchor cannot expand, you're not going to get as robust fixation. So when I insert the anchor I typically start by inserting the first few millimeters by hand. I'll then use the mallet a few gentle taps and it goes in very, very smooth. Now once we get our anchor in we're going to take everything out. And there's three strands to this anchor. And we want to set that anchor by gently pulling all three strands. And you can see this allows the anchor to deploy. And now we're shaking the table with just pulling these three strands. And you can see how robust and strong that fixation is. Once we've set the anchor now we're going to separate these three strands. So I'll typically pass off. We've got a passing suture with a loop on the end. And that's the loop that we're going to pass around our labrum for the repair. But to start I'm going to pass that off. I'm going to take the other end of that suture. And then the repair suture and the repair suture has a purple mark on it. And one tip is it's easy to find which suture is the repair suture because it's longer than all the rest. And so grab the longest repair suture. We're going to pass that off to our assistant. And now we have our passing suture that I typically separate. And I'll run just a few times. And this eliminates any any tangles within the cannula. So you can see with our shuttling suture we have one end with a loop on it. And for the inversion repair technique this is the end that we're going to pass around our labrum for the repair. Now we're going to use the SwiftStitch suture shuttling device. And what we're going to do is with this looped end, you can see below the base of the loop the suture is thicker. Now typically I want to grab about a centimeter below the base of the loop with my SwiftStitch to pass the suture. So we're going to use the SwiftStitch. We're going to grab it about a centimeter below. And that's going to be how we're going to pass this looped end of the shuttle suture around the labrum for inversion repair. Now as we go into the hip joint, you can see we've got our SwiftStitch and we're going to go just below that anchor. And work into the joint. Now we're going to come down and you can see where our suture is. We're going to bring a little more suture into the joint, and then bring our SwiftStitch back to reduce any tension on that suture. Now another tip is when we deploy the suture, we're going to simply spit the suture out, pull our hand straight back in the middle of the loop, and then close the jaws. And you're going to see that will prevent any entanglement with the jaws of the SwiftStitch while you're trying to deploy that looped end of the shuttling suture. Now we're going to work and we're going to go around that labrum. We're going to use the SwiftStitch, grab our suture. And again, as we come out of the joint, I'm going to watch these sutures to make sure we don't have any tangles. And you can see that pass very nicely. So now you can see we've passed the looped end of our shuttle suture around the labrum for our inversion repair. Now we're going to take the repair suture. And one tip is the repair suture again is going to be longer than the other two sutures. So that's how you can quickly identify it. We're going to smooth the end of this suture out. And that's going to help it pass through the internal mechanism of that anchor. And then once we've done that we're going to pass this repair stitch through the loop. And then we're going to fold it over on itself right where the purple mark is. And I actually typically will go right at that purple mark. We're going to hold it and pinch it. One thing that really helps in passing too is I pinch the repair suture right above where it's looped on itself, and I hold that as I pull the other end of the shuttling suture. And as we go and pass this repair suture, once it gets into the cannula, I'll do a few small short tugs with that shuttling suture. And you can see now we've passed that repair suture around the labrum again in an inversion technique. So you can watch as we're passing that repair suture. And once we get it to where the tension is close to how we like it, I typically move back into the joint and I'll watch that labral tissue. And as you tension it, see how this inverts the tissue and sucks it up very nicely right on that acetabular A rim and you can see now it's tight and you can keep the suture if you'd like. And that allows you to retension it later in the case. In this particular example I think our tension is great. So I'm going to go ahead and move to view above the labrum where that repair suture is. I'm going to use the mini tape cutter which is hip length. And this allows you to cut the end of that suture. Now we're going to pass the end of that repair suture through the mini tape cutter. And as we go into the hip joint you can see on your screen this mini tape cutter allows you to cut that suture flush right at that acetabular rim. We have now switched our camera. So we're viewing looking anteriorly on our right hip through an anterolateral portal. And we're working through a mid anterior portal using a curved guide. Now what's great about this curved guide is it's got a 20 degree curve. And it also has a mark which allows you to see exactly the orientation the curve is going. Now you can see that black mark is going to indicate which way the curve is directed. And that's going to help us to place the proper trajectory on our drill guide and our subsequent anchor placement. Sometimes it can be difficult to get this more anterior anchor, and if you place the curved guide with the curve two anterior, you're likely to skive out the front and not get good bony fixation. So what I'll typically do is turn my hand. And again this is a right hip. So I'm turning my hand counterclockwise. I'm angling the curve super laterally. So I'm coming more superior. But also getting into the nice bone within the acetabulum where we're going to get our anchor fixation. So you can see you've got the labrum. We've got our bone I'm turning my hand. So we're angling that curve a little more superiorly. And at this point I'm going to tap our guide in to get it to set and gently set that guide. Now we're going to use our flexible drill. Again we're angling a little more superiorly versus straight anterior. We're going to drill. Now one important thing with this curved drill in guide is that when we place our anchor, we'd like these sutures to line up with the flat part of this drill guide that helps the anchor go around the curve a little more smoothly. And you can see as we go, I'll typically start the anchor by hand to get it set. Again, the sutures are lined up with the flat portion of this guide. And then as we gently impact the anchor, you can see we're now flush with the guide and the anchor has been inserted all the way. Once we've done that, we can take everything out. Again, we want to gently pull those three strands and that deploys the anchor. So we're going to use a C grasper and we're going to separate out our suture that has the loop on the end. And to confirm that we have the correct suture. So you can see the looped end is the one that we've got. So we're going to push this a little more into the joint. So we've got some slack on that. We're going to use our SwiftStitch suture passer. You can see we now have our suture that we're going to pass with some nice laxity on it. We're going to grab that suture. And again, this is the shuttling suture with the loop end. We're then going to pass this around the labrum and into the joint. And we're going to go a little past point and then come back to take any tension off of that suture. We're going to deploy that. And at this point we're then going to use a post grasper that has a slight upward angle to come underneath that labrum. Grab our suture. And the great feature about this post grasper not only the up angle that allows you to grab that suture within the central compartment, but also the post which will allow that suture to slide as you come out of the joint, and that will remove any tension from that stitch as we pass it. So now we've passed our shuttling suture with the looped end around the labrum using the SwiftStitch suture passer. We're going to take the end of our repair suture, and we're going to pass that through the loop and bring it to the point with the purple mark. And that's where we're going to fold it onto itself. So you can see very nicely. We've got the repair suture folded onto itself with the purple mark. We're then going to take the other end of our shuttling suture. And I always like to maintain a gentle grasp and kind of pinch the repair suture in view. Pinch that repair suture as I bring it into the cannula. And that's going to help it pass smoothly through that inner mechanism of the repair anchor. Now a few quick tugs on that shuttling suture. And you can see we now have our repair suture that is in an inversion repair technique. So as we tension it you can see it's going to invert that labrum very nicely right against the acetabular rim. All right. Here's our final repair. We've used 1.8mm knotless FiberTak anchors in the hip to do a knotless labor repair. We're now going to let traction down. You can see once traction is down, we've got a nice seal between that labrum and that femoral head.

F. Winston Gwathmey Jr, MD (Charlottesville, VA), demonstrates an acetabular labral reconstruction using a graft pull-through technique in which the graft passes through three precinched Knotless FiberTak® soft anchor loops.

Acetabular Labral Reconstruction Using Precinched Loops From Knotless Hip FiberTak® Soft Anchors

Today we're performing a circumferential label reconstruction using a allograft tendon and knotless FiberTak anchors. So we have pull through technique where we pre-position the loops and pull the graft into the joint to achieve a circumferential reconstruction all the way from anteriorly to posteriorly. I spent about 15 minutes or so kind of preparing this joint. It's actually a pretty good joint. We've got good cartilage here. Labrum. This was actually pretty ossified. As you can see, the labral tissue is pretty degenerative. We've removed the majority of the labral tissue you can see anteriorly probably around 5:00 down here. We have some residual labrum coming down here into the tail. So you can see the transverse ligament coming down here. This will be kind of where we start our label reconstruction at the bottom here. We'll work our way around the top I always use the fossa as my clock. And so here at the top of the key this would be 12:00 going straight north. And so this is the anterior quadrant here. So between 3:00 and 12:00 really this is the critical portion for your label repair and reconstruction. Most labral tears occur here. Working our way around the top, you can see we've prepped the entire rim. Really important to maintain your capsule up here. This capsule we're going to repair here at the end. As you can see, we've prepped the entire acetabular rim and then moving around the back of the joint, you can see we've gone all the way down to essentially the tail in the back. This right here is my posterolateral portal and it's part of the surgery. What we're going to end up doing is we're going to shuttle the graph from this position to the most anterior portion of the joint up here, but we've got to loop it across the actual top of the joint. We prepared about a 14 millimeter graph for this to see if it's going to fill this entire space. Looking at the external view here, pretty much all my hip scopes, I use the anterior lateral portal and a mid anterior portal. I'll usually take this portal a little bit lateral of the line, extending from the eyes down to the knee and slightly distally. This can be my mid anterior portal. I use a Dalla porta or a Dalla portal, so a distal anterior lateral portal. This is my main portal that I put my anchors around the rim. I'll put my anterior anchor into this portal and then my rim anchors my like basically any anchor between 2:00 and 10:00. Through this portal. And I also made a posterolateral portal, as you can see back here in the back. This posterolateral portal is going to be where I pull the graft through. So this entire reconstruction will be done through four portals very reliably. If I have a tough hip, sometimes I'll make an accessory portal up here, sort of between my two portals, just for suture management. But in this case, I think I'll be able to do it all through these four portals. We're going to place our first anchor in the most anterior position. This will be our pull through anchor. A couple of things about this anchor that are important. One, you want to get it low just off the rim. But two, this has to be a very solid anchor. You're going to be pulling the graft of this anchor. So the purchase here is pretty important. You normally can put this in through the anterior portal on a low position on the face. This anterior anchor would have to use to shuttle the graft through. So I'm going to use a FiberTak. It's 1.6mm hole and we use 1.3mm tape. Here you get more bone the lower you go. If you put your first anchor kind of in that 3:00 position, you'll kind of run out of bone. So that'll be anchor number one. We're going to use the dollar portal to portal to place or not? Fibertaks. So I use a straight guide here. I'm going to place this first anchor at approximately the 2:00 position. Again, the beauty of this anchor is just how close you can get to the articular surface so that when your graft goes in, it will re approximate the labral junction anatomically. We're going to just basically pass this suture through. And with this there's a tiny little line there. You kind of put it toward that line and you literally just pass it. So what I'll do is I'll pull this in until we form a loop here. What I'm going to do is make sure we maintain this loop. You want to make sure you have a big enough loop to fit the graft through, but if you have too much loop, then you're going to have just too much suture in the joint. We'll leave this loop right here, which is a big enough loop for us to fit our graph through. So then what I would do is I would take a snap. And this is all about suture management for me. Snap this in the front. So here's a 2:00. And then we're going to do one again. I usually follow the fossa. We're going to put one up here on top. Let's find that junction. Where. We placed our second anchor in up here on top we're going to shuttle. Make sure these things glide. And then we're going to pre-position this loop again. We're just trying to make a belt loop for our belt. This end goes into the loop here. And again we just want to make sure that we have it positioned properly so it will deploy into the anchor. Pull it into the joint nice and slow. Your assistant can tug on the loop so you can make it just the right length. You don't want that loop to be too tight, because then the graph won't shuttle through very easily. Here we've placed our third anchor here at approximately the 10:00 position posteriorly. And this is going to be our back looped anchor to orient us. So you can see here we have our most anterior anchor, which is our shuttling. Anchor is a FiberTak with a SutureTape within it. We're going to use that to actually attach the graft. We have our first loop here at approximately 2:00. We have our second loop here at approximately 12:00. And then if you want to look around the back, we have our third anchor here at approximately 10:00. And then there's our posterior lateral portal there in the back. That's we're going to shuttle our graph through. So the graph is going to come through that portal through this loop, then this loop, then this loop. And then we'll secure it anteriorly. So this is the suture we're going to use to shuttle the graft. I have the anterior suture held in my retriever here. So I have the anterior shuttle through the retriever. This is going to have to go all the way to the back of the joint. As you can see. However to make this technique work, I have to shuttle it through each one of these little loops. So we're going to do is I'm going to park it inside the joint. And I'll come through my first loop and I'll pull it through. So now you can see you see the first loop. And then the second loop there. So you can see now I'm through the second loop. And then through the third loop. Well you can see is you can see it's through all three loops. So now we've placed this posterolateral portal in a position where we want the graph to kind of end. So now I'm just going to use this posterolateral portal to grab it through here. Pull this thing back some. Good. And we'll go through straight through. Straighten. So as you can see, the suture from the anterior most anchor is coming through the first loop. The second loop and the third loop and then out the back. And so we're going to basically pull the label graph from posterior to anterior. We'll secure it anteriorly. And then we'll use each of these sequentially to tighten the graft up onto the rim. So we were using an 8.25mm TRIM-IT cannula here. We had to tie a knot. So I'm actually going to shuttle this anterior suture back up to the TRIM-IT cannula. So now we have this here. And what we'll do is we'll use this to pull the graft into the joint. So I use a straight Keith needle here. Pull this through. And this has to come in through the very front of the graft here. This is going to be the anterior most portion. I'm going to pull this through. And then I come back around one time. And what I'll do is I'll tie it to itself. Because I don't want this to slide once it gets into the joint. So we're going to put this back on the back side of the joint so that when you tie it this becomes the front. And we'll tie it across the back. So now we have the graft secured anteriorly with a knot. And as I pull this it will it will actually tighten the other stitch. So now you can just get the graph through the first loop. So pull a little bit. Good. So that's the first loop. Now the second loop. So now you're through the second loop. So here we are anteriorly. All right. So we're going to tie the interior anchor. We've secured the graph anteriorly. All right. And now you can see we have the graph pass through each one of these stitches sequentially. So here's our most anterior one. Here's our middle one here. And then here's our posterior one back here. So you can see the graph is coming from front to back. And all we got to do now is kind of put the graph where we want it. And then so pull the anterior one first. So you kind of hold the graph where you want it. That's good. There. Now pull the second one. So I'm going to hold the graphics out where I want it. Go ahead. And then the third one. We've secured the graft entirely at the level of the transverse ligament using our interior suture anchor. And then we have secured it here anteriorly. Superiorly. And posteriorly. And you can see it goes all the way down the back. And so at this point you've converted a very complex labor reconstruction into a simple labor repair. Because we'll place anchors here, here and here to give you the final reconstruction and secure the entire graft against the joint. So the first we're going to place in here. I'm coming to an anterior portal. I'm going to put the anchor actually on the articular surface. So we So he placed it into your anchor. I'm going to go ahead and pass it. Now we're going to place this stitch between our anterior and our superior anchor. So we're going to just come right through the labral junction. It should go pretty easily to place the repair stitch through. And then what I like to do is I like to grab the round stitch, which has a loop on it, as well as the repair stitch and pull them out of the joint together. So pinch it here. Pull it through. And is this going to be kind of secure the graft across the entire rim. So now you can see. So we have our FiberTak up front which we shuttled through. We have a low anterior anchor. We have an anterior anchor anterior-superior superior. This is the anchor we're just setting right now. Do we have one posterior? We have one further posterior. And then we'll have our last one here in the back. And so what we're going to do is we're going to secure the graph back here. And then amputate the end of the graph to make an anastomosis. We're going to secure this at the very posterior aspect of it. I'm going to park this thing in the joint. Here we have the graph secured with the stitch behind it. So I can just grab this behind it. I'm going to grab this stitch here and get it the stitch where I want to go I'm going to grab the looped stitch. So grab this and this. You see we have them together. All right. So we're going to pass this through. I'm going to pinch it. Into the joint. Good. Now we have it secured all the way in the back. So here is our final construct. Tied at the front. And then you can see as we come around the top how we've secured it every single station using Knotless FiberTak anchors. We've got nice restoration of the Chondrolabral interface here. So the cartilage comes, the labrum is anatomic. It's not off the joint. It's right at the rim. These anchors are nice in that you can put them right at the actual rim. And then as you go all around the side and then even down to the back, you can see we've performed a circumferential reconstruction. Now back here, sometimes what we actually do is actually we'll pierce the labrum to make sure that I have good security of the labrum posteriorly as well. So letting traction off what you'll see is you'll see the seal is restored. So as we put the hip back in the socket you can see it actually we have labral contact circumferentially around the labrum as you can see.

Benjamin G. Domb, MD (Chicago, IL), demonstrates a cadaveric segmental acetabular labral reconstruction of the hip using Knotless FiberTak® soft anchors to restore the suction seal.

Segmental Acetabular Labral Reconstruction With Knotless FiberTak® Soft Anchors

This is Doctor Benjamin Dohm demonstrating a large segmental labral reconstruction using the knotless pull through technique. So to begin with, we have identified the area of lack of labrum, which goes from here all the way to here. So anteriorly we are almost down to the attachment of the transverse acetabular ligament. We're at about 430 on the clock face. And then looking around posteriorly this defect goes to here where we have labrum again. So we're at about 11:00. So this reconstruction will go from about 11:00 posterosuperior all the way around here anteriorly down to 430. So we're just past the psoas u here. Hear? So we'll begin by drilling a pilot hole, which will be the docking hole for the anterior point of the graft. So we'll place our pilot hole here right up against the native labrum where there's good labrum. And we want to aim this pilot hole so it goes into the superior pubic ramus. If it's going anywhere at all, you always want to check the bottom of the hole with a guidewire and sound it and make sure that there's a bottom. So there is a good bottom. So now we can switch the drills. So next we'll put in our knotless FiberTak anchors all the way around the periphery of the acetabulum. This first one will go quite close to the docking hole. And now we pass the anchor. We'll give it a good push to get as far in as we can. And in this case, we didn't need a mallet. We'll give this a slow pull just to set the anchor here. So we have good fixation there. Now we'll retrieve this through the distal lateral accessory portal. Okay. So that's our first anchor. Now we're going to place a series of anchors all the way around the rim. Because these anchors are very small. We can put them quite close together. And because they're suture, we're not eating up bone while we're doing it. Sound the bottom again. And then we'll place our anchor. Set our anchor. So I've drilled the last anchor here, which abuts the native labrum, and actually will create some overlap between the graft and the native labrum. And here I'm retrieving it Retrieving it through the Dlap portal. Because I drilled it through the posterolateral portal. So ultimately all of my sutures are coming out the dlap portal. The anterior two anchors were placed through a modified anterior portal. The majority of the anchors in the anterolateral quadrant were placed through the distal lateral accessory portal, and then the most posterior anchors can be placed through the posterior lateral portal, and generally, having all three of those portals at our disposal gives us the correct variety of angles. In order to access any part of the acetabulum for anchor placement. So at this point we'll make preparations to introduce the graft. So we'll start with posterolateral portal here. So we place this switching stick posterior to the most posterior of the anchors. And then we're going to place. A KingFisher in that spot. Here's our KingFisher posterior to all the anchors. Now we place a switching stick through the modified anterior portal, and we'll prepare to introduce the graft through the modified anterior portal. So here we can see the graft. The graft has been prepared to a thickness of about six millimeters. This can be an allograft using a tibialis posterior or a peroneus longus or a tibialis anterior. Any of those can work quite well. Currently, the graft I've liked the best tends to be the tibialis posterior, so we've prepared this with FiberLoop with or without. The tape modification can be used to secure the ends. And then on this end we've secured it to a PushLock anchor which will be for our docking anteromedially. So at this point my assistant will hold the PushLock and I will take the what will ultimately be the posterior end of the Of the graft, and we're going to enter this into the joint through the anterior portal. So the posterior end is coming through the anterior portal. And now we'll retrieve this loop through the posterolateral portal. Pull the graft through the joint. And at this point the PushLock follows the graft into the joint. So we now check our placement. Make sure we're anterior to all the anchors. And we are. And posteriorly make sure we're posterior to all the anchors. And we are. And so now we will bring the PushLock into the docking position. And we can toggle the graft as we see fit to secure it in place, and then secure it with the PushLock anchor anteromedially in a way that abuts or overlaps against the native labrum and transverse acetabular ligament attachment. At this point, we'll use a switching stick with numbers and wheel size. The wheel size, the TRIM-IT cannula. So a TRIM-IT cannula here can be five or even four. Okay. And now we can cut that suture. And now we're using the suture. At this point we are going to pass and cinch each of the anchors sequentially. So we'll start with the most anterior anchor. Pass the suture around the graft with the suture retriever. Retrieve it here. So now we take the suture and pass it through the loop of the shuttle like so. And white should overlap the white, but should not overlap the part with the stripe. Yeah. There is a little mark there, a little purple mark. And that is roughly in the right spot for the overlap. So then we pull the shuttle through like so. Now that we've pulled the shuttle through, we can tension this down. We'll want to make sure it falls in the right place on the graph. So now we watch that cinch our graph into place. Perfect. Okay. And we cut our suture and flush. Okay. And now we repeat. So we move on to the next anchor. Pass the suture around the graft. And once again shuttle through our suture. Okay. And again. The suture now cinches our graft into place. So another important thing to note is after we've passed the repair suture around the graft, we need to retrieve the end of the shuttle that has the loop. And that is the end that has FiberWire suture, not the tape end. So you can see this is tape on the left. This is FiberWire suture on the right. So we want to retrieve the FiberWire suture in. So that way we'll always have the correct end retrieved. Okay. Good. And we secure our graft suture retriever next. So at this point it's important to position the sutures correctly so that they cinch the graft to the right spot. So we'll unclamp the last anchor here. And we're going to retrieve the repair suture here around the graft. And just like we've done with all the other anchors, get the end of the shuttle that has the loop, we'll pass through the loop, double over the white portion of the suture and then use the shuttle to pass the suture back through the ankle. And that is going to. Complete the reconstruction there. So we have nice approximation to the. Native graft. And now we can put a little tension on the end of the. The end of the graft. And now we'll amputate the end of the graft. So notice. With this technique we avoided having to do any sizing. So having now completed the. Reconstruction we can see the reconstruction goes all the way from anteriorly at the attachment of the tail all the way up here around the anterolateral quadrant and then around to the posterolateral quadrant to 11:00, where it overlaps with native labrum. So that came out very nicely. And you can see another view. Here is a bird's eye view where we can look at the whole graft essentially the Nautilus FiberTak anchor that we've employed in this reconstruction utilizes a 1.8mm hole, which can be used even in the very thin parts of the rim, like anteriorly near the iliopsoas. So it's a very useful tool, and the ability to control the tension gives us the controlled tension, anatomic positioning of the graft as we synch each of the sutures. So at this point I'm lifting up the capsule. I've preserved the whole capsule during the procedure. And you can see now that the graft is creating an effective seal, sealing the ball in the socket and sealing the lubricant fluid in the joint, which is critical for the maintenance of the hydrostatic distribution of force across the hip joint.

Travis Menge, MD (Grand Rapids, MI), uses the Knotless Hip FiberTak® soft anchor for a revision acetabular labral repair.

Revision Acetabular Labral Repair Using the Knotless Hip FiberTak® Soft Anchor

Hi, my name is Doctor Travis Menge and I'm a sports medicine specialist in Grand Rapids, Michigan. Today I'm going to talk about the Arthrex Knotless FiberTak anchor and the many advantages that it offers in hip arthroscopy. I'd like to start out with a case today of a patient with recurrent hip pain after a prior hip arthroscopy. It's a 36 year old active female who presented to my clinic approximately a year and a half after she underwent a hip arthroscopy with labor repair using three anchors, correction of her Fe and capsular closure. She did well initially following surgery. However, approximately 9 to 12 months after this initial surgery, she developed gradual onset of what she described as new or different pain within her hip. We started a new trial of extensive conservative treatments, including oral anti-inflammatories, formal physical therapy, ultrasound guided steroid injection within the hip ice rest, and activity modification. You can see on the radiographs on the left she had appropriate correction of her bony face, and on the right you can see an MRI demonstrating one of her prior anchors. And what's interesting about this image is you can see what appear to be dense adhesions between the capsule and the labrum, with essentially a complete loss of that normal space, which you'll typically see between those two structures after failure of extensive conservative treatments. This patient had continued debilitating hip pain that affected both her activities of daily living, as well as her ability to work at her desired level. She therefore elected to undergo revision arthroscopic hip surgery, and you can see in the photos beginning on the picture on the left were in her left hip viewing from an anterolateral portal. Looking anteriorly, you can see a wall of dense adhesions which had formed between the labrum and the capsule. This has resulted in eversion of the labrum and loss of the suction seal mechanism within the hip. As we carefully work using electrocautery to clear these adhesions and recreate the Recreate the normal plane between the labrum and the capsule. You can see that. Immediately below the dense wall of scar tissue was a knot stack from one of her prior anchors. She had a prior repair with an anchor that used a knotted construct, and you can see that that suture knot stack and the knots that resulted were directly below the center of that dense scar tissue. As we continue to work, we remove that knot stack and continue to elevate that capsule and recreate the plane between the capsule and the labrum as we continue to work posteriorly. We're now viewing from a mid anterior portal, looking posteriorly, and you can see another one of the anchors had a suture which had loosened from her prior surgery. So we went in and removed this loose suture, which again with a knot, was one of the problems with this particular construct. And it is for these reasons that I have switched in my practice to the knotless FiberTak Tech anchors for all of my hip arthroscopy cases. To start, they offer a number of innovative features and design, which you won't find in any other products currently on the market. They're an all suture anchor. They're knotless, and they have a very small footprint of only 1.8mm. This allows you to place anchors very close to the acetabular rim, as well as offers greater points of fixation in your repair construct. Additionally, it offers excellent versatility with both straight or curved drill guides, which allows you to use the proper trajectory as well as the perfect anchor placement for every case. As you can see in these photos from the revision case discussed earlier, we're able to get our anchors immediately adjacent to that labrum on the very edge of the acetabular rim, and we get a repair, which in this case a revision repair, which offers a repair with no knots, stacks, perfect tension, and perfect anchor placement. You can see in these videos starting with the video on the left. These anchors also offer excellent Precision with control of the labrum and your repair construct. The video on the left shows the ability to invert the labrum during your repair. Versus the video on the right where we can invert the labrum during your repair. This adjustable tension allows you to precisely control your labrum with either. Eversion or inversion and get the repair perfect every time. Furthermore, you can tension these anchors with the traction up or down, allowing you to get the perfect suction seal between that labrum and the femoral head. Altogether, this anchor offers reliable, reproducible, and high quality fixation. As discussed in the case earlier, it eliminates not stacks and decreases the risk of those capsule labral adhesions. Additionally, it minimizes suture tension variability, which we all know can cause and result in not loosening and variability from case to case between surgeons. Furthermore, there's greater access for anchor placement along the acetabular rim, given that small footprint, as well as the versatility with either the straight or the curved guides, and improved ability to recreate the anatomic labral seal and that suction seal mechanism within the hip as you're able to either invert or invert the labrum, as well as tension the sutures with either traction up or traction down. So looking at some of these photos, these are examples of both labor repair as well as labor reconstruction using the Knotless hip FiberTak anchors. And you can see amongst all of these photos a very reproducible high quality repair or reconstruction with no knots and excellent tension that is reproducible every single time. So in summary, going back to our case that we discussed earlier, that patient is now almost a year out from her revision arthroscopy and is done exceedingly well. She has no pain within her hip, is back to all of her sporting activities and back to work without any limitations or continued symptomatology. Thank you.

Knotless FiberTak®-Softanker für die Hüfte

Child (D)

Product

Erleichtern Sie die arthroskopische Labrumrefixierung im Acetabulum mit dem knotenlosen SutureTak-Anker für die Hüfte durch die Kombination aus bewährtem1, reproduzierbarem Fadenankerdesign und -insertionsverfahren mit knotenloser Weichteilfixierung. Bohren Sie mit dem Setzinstrument präzise ein Loch in den Pfannenrand. Das Setzinstrument wird in dieser Position belassen, damit der Fadenanker anschließend in gleicher Richtung wie die Bohrung eingebracht werden kann. Führen Sie das Fadenende zurück in den Verschlussmechanismus, sodass die Spannung des Nahtfadens zur knotenlosen Weichteilfixierung unter direkter Darstellung eingestellt werden kann.
Referenz
1. Arthrex, Inc. LA1-00017-EN_A. Naples, FL; 2015.

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.

Benjamin G. Domb, MD, (Chicago, IL) demonstrates an arthroscopic circumferential acetabular labral reconstruction using Knotless SutureTak® anchors and a graft pull-through technique to create a low-profile construct. He outlines the surgical steps necessary for performing the procedure and describes how to make the technique more reproducible.

Arthroscopic Circumferential Acetabular Labral Reconstruction Featuring Knotless SutureTak® Anchors

This is Doctor Benjamin Dohm with a demonstration of arthroscopic circumferential acetabular labrum reconstruction using the Knotless SutureTak anchor. Here we see the rim of the acetabulum has been prepared circumferentially. In the case of an irreparable labrum, an irreparable labrum may occur due to calcification of the labrum or due to lack of substantive, sufficient healthy tissue. Or it may occur in the revision circumstance after a debridement or a failed repair. So we can move all the way from posteriorly at the posterior insertion of the transverse acetabular ligament here at approximately 8:00 on the clock face, all the way to anteriorly at 5:00 at the anterior insertion of the transverse acetabular ligament. We'll begin by drilling the most anterior anchors. So here we are at 5:00, and we'll drill this 5:00 anchor through an anterior portal. Again, this is at the anterior insertion of the transverse acetabular ligament. Prior to placing it, we'll pass a guidewire to check that the hole has a bottom. So we found the hole to make sure it has a bottom, and that we have not penetrated into another location, such as the iliopsoas fossa. So that first hole will be for a PushLock anchor. The every sequential hole from this point forward will be a knotless SutureTak anchor. We'll now place the Knotless SutureTak anchor here at 4:00 on the clock face Antero inferiorly, and all of these knotless SutureTak anchors are placed through the distal lateral accessory portal. After placement of each of the anchors. We'll take the drill sleeve out and use a half pipe, and we'll clamp the sutures to the drape. It's important for suture management to clamp all of the sutures in order, so that they can subsequently be released in order. It's my personal preference to place all of the anchors prior to introduction of the graft. However, it is also possible to place the anchors sequentially after the graft has been introduced. The advantage of placing all the anchors beforehand is that the visualization is not compromised by the bulk of the graft itself. So here we work around posteriorly. We're now at about 10:00 posterosuperior to 9:00 directly posteriorly. And here we're all the way down to about 730 on the clock face at the posterior insertion of the transverse acetabular ligament. The next step in this technique is to introduce the graft and we introduced the graft back end. First you can see placement of all of the anchors. Here we have anchors circumferentially around the acetabular rim all the way from posterior inferior around to anterior inferior. So all the suture anchors are placed before introduction of the graft in this technique. So for the knotless pull through technique the next step is creation of a posterior lateral portal. And we'll place a switching stick through this posterior lateral portal posterior to all of the sutures. That's important. This comes in posterior to all of the sutures. And through this portal, over a half pipe, we'll introduce a KingFisher. The KingFisher grasper will be used for the pull through of the graft. So this KingFisher is now posterior to all of the suture anchors. Now we'll focus our attention to the anterior portal. We'll place a switching stick through the anterior portal, this time anterior to all of the suture anchors, and we'll pass a half pipe over this switching stick and then use this half pipe to introduce the graft. The graft will be introduced. Back end. First back end on the left. The front end on the right. Here we have the front end attached to a PushLock anchor. And we have used a FiberLoop to secure both ends of the graft. We generally use a tibialis anterior graft, although a variety of graphs can be used, and generally we'll target a graft thickness of approximately six millimeters. Note that the PushLock is already attached to the front end of the graft, which is where we will secure the graft Antero inferiorly, and the back end of the graft with the whipstitch will be pulled out through the posterolateral portal. So we'll introduce that back end of the graft through the anterior portal. And then the pull through step of this technique is to pull it through the posterolateral portal. It's also important that we are not trying to size the graft to fit a defect. One can do that and there is an excellent measuring device made for this purpose. But any inaccuracies in the sizing of the graft can make for a very difficult reconstruction. So instead of trying to size the graft, we'll instead use the graft at its full length, which is about 30cm, and introduce it. Here I'm pointing out the way that the loop is brought out, the end of the graft. We try to bring one end out behind the suture and the other end in front of the suture, right through the end of the graft. By having these two suture ends coming out different places in the graft, this enables us to control the graft position, the position of the end of the graft once it's in the joint, and to adequately compress that end against the bone in the anterior inferior anchor location. So here I use a suture retriever and take the whip stitch which is attached to the posterior end of the graft. We'll pass this suture through the anterior portal. So the posterior end of the graft is coming through the anterior portal. We'll then retrieve that whip stitch with the KingFisher which is through the posterior lateral portal. So we pull that whip stitch from the anterior portal out through the posterior lateral portal. We'll place a half pipe here and remove the suture retriever. And then using the whip stitch that I've now passed all the way out through the posterolateral portal, we'll pull the graft all the way through the joint. So you'll see the graft pass through the anterior portal and come out the posterior lateral portal. That is why this is called the knotless pull through technique for circumferential labral reconstruction. So the graft is pulled through the posterolateral portal, and we now pass the PushLock anchor attached to the anterior end of the graft through this anterior portal. We'll now use the PushLock anchor and the suture, which is attached to the anterior end of the graft, to manipulate the anterior end of the graft into place. So as we pull tension on the suture, you can see that we pull the graft back into the joint. So pulling it from posterior back anteriorly into the joint. Here comes the end of the graft. And note that the graft is posterior to all of the sutures. So we've cleared all the sutures and we bring the graft across the joint to anteriorly. And then we'll use the PushLock anchor to anchor the anterior end of the graft to the anteroinferior extent of the acetabular rim adjacent to the insertion of the transverse acetabular ligament. And again, we can use those sutures that are coming out different spots on the end of the graft to manipulate the end of the graft to obtain a good position. Now we simply pass the repair suture from the knotless SutureTak around the graft, retrieve it on the other side, and we'll do this sequentially. So we pass that repair suture around the graft. We'll now go back in with the suture retriever. Put a little bit of slack on both ends of the shuttle suture the FiberLink shuttle suture. Pull on the non looped end to leave the looped end and then pull out the looped end. That's how we can differentiate which is the non looped and which is the looped end. So we now have coming through the cannula the repair suture which is passed around the labrum and the looped end of the FiberLink. And you see here I'm holding in my right hand the looped end of the FiberLink. I will pass the white portion of the Knotless. Suturetak. Anchor the skinny portion through the loop of the FiberLink and overlap. White with white. The white overlaps with the white, but never overlaps the part with the stripe. And now through the distal portal where we have the non looped end of the FiberLink, we shuttle the suture through by pulling on that other end of the shuttle coming out the distal portal. This threads the repair suture back through the anchor. And then we can simply tension the suture to achieve our repair. We may want to tension the graft a little bit as we perform these repairs, as we tension each of the sutures, in order to make sure that we have appropriate tension on the graft. So one at a time, we unclamp the sutures from the anchors, pass the suture around the graft. Shuttle it back through the anchor and tension to our desired tension. Because the knotless SutureTak anchor is essentially a self cinching suture with a one way stop. We can pull the suture to the desired tension and no knots are needed. We don't need to have an inserter in the joint. We can simply pull on the end of the suture. And that is one of the exceptional things about this technology, which allows us to place all the anchors before introducing the graft, is that it can be tensioned after the graft is in, without an inserter in place. After we've placed all of the knotless SutureTak anchors the last, the very last anchor will pass through the graft. So this is the last Knotless SutureTak anchor. We've placed this through the graft with a Scorpion. And then we'll use the shuttle to shuttle it back through the anchor and repair this very end of the graft. The reason to pass that last suture anchor stitch through the graft is because it acts as a rip stop. And now, finally, we can amputate the end of the graft so that we leave it perfectly sized every time. So every single time we do this, we'll achieve a perfect size to the graft. You can see now we've completed a circumferential labral reconstruction all the way from the posterior inferior acetabulum, all the way to the anterior inferior acetabulum. So essentially end to end from the anterior transverse acetabular ligament to the posterior transverse acetabular ligament. As we take off traction, we see we have an excellent seal of the labral reconstruction against the femoral head. The intention of any labral work is to reproduce its anatomy and seal.

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Hip Labral Repair Using the Knotless SutureTak® Anchor Surgical Technique

Benton A. Emblom, MD, (Birmingham, AL) demonstrates 3 different suture configurations for acetabular labral repair using Knotless SutureTak® anchors and Hip Labral Scorpion™ suture passer. In this cadaveric demonstration, Dr. Emblom describes his rationale for using a standard simple, an inverted simple or labral base mattress stitch configuration, and outlines his surgical steps for performing each configuration.

Acetabular Labral Repair with Knotless SutureTak® Anchors

All right. I'm Benton Emblem from Birmingham, Alabama, at the Andrews Sports Medicine and Orthopedic Center. We're going to demonstrate today the Nautilus 300 SutureTak and three different configurations of repair. The primary simple repair, followed by the inverted simple and the labral base mattress configuration. We've already done our prep work here. We've already done an acetabular plasty of the rim of the acetabulum, our capsulotomy, and our cleanup and prep work in order to enable access and appropriate maneuverability during the procedure. So first, through our mid anterior portal, we'll place the drill guide for the three zero hip length SutureTak. And we want to be able to see exactly where we're placing the suture anchor. So we don't inadvertently place the anchor too high or too low and penetrate the joint. We can see here where the drill guide is going in, and then the assistant will lightly insert the anchor to make sure it's over the aperture of the tunnel, and then we'll pound it into place. Like so. I'll take our ring. Suture grasper. And what we'll do first is, since we're doing this all through one cannula, we want to make sure that we don't have any twists in our suture material so that we avoid creating a tangle when we're passing it. So what I'm going to have you do is just pull gently on the the looped end of the suture. I've introduced some slack into the system there, so I know which one you're actually. There we go. You're pulling on the on the looped end. So I'm going to grab the one that's entering the joint, which is right here. And we're just going to make sure we don't have any slack in the system. So now we'll load the labral suture. The white portion of the labral suture is loaded into the jaw. We're going to have our assistant hold the suture up up top so that we don't wrap around the suture. And then we're going to make sure we keep the end of our Scorpion down on the bottom end of the cannula. So now we're introduced into the hip. We're going to reach in. We're going to take a bite, pull back and then reach and grab our looped in. I'm going to use the looped end to feed the wide end of the repair suture through, and then we're going to fold it over itself. White on white. We don't want to fold it with any of the colored suture, because it's slightly thicker. And it can impede the passage of the suture through the anchor. Now we're going to feed the suture in through the cannula. Pull it out. Reach in. There's our repair. Yeah. So we've we've fed our loop through the retriever here. And we're pulling this through our tensioner cutter instrument. And we're able to push this into the joint and feed it really right into our pilot hole here. And push down on the anchor itself and tension the labrum until we get an appropriate physiologic tension. And then we can squeeze, cut and and cut the suture off within the hole itself so that we don't have any suture material outside the drill hole. Here we're going to demonstrate the inverted simple stitch. It's important when you repair the labrum that you get good labrum to cartilage contact. So if the suture material pulls the labrum up away from the femoral head. That can actually be counterproductive relative to the function of the joint. So we're going to insert the anchor just like we did on the previous. Component. Similarly here we're going to reach in and grab one limb of our passing stitch to ensure that we don't have any twists. And what I like to do here is just introduce a little bit of slack into the system and then have the assistance, the assistant pull gently just a little bit on the looped version. There we go. And that will allow us to pull the one that has slack remaining when doing the inverted simple and labral base horizontal mattress repair configurations, it's important to understand where to grab the looped into the suture. As you can see here, the last two inches or so of the loop suture is thicker. Where the loop comes back on itself. You need to grab that suture in that zone of the suture because it's thicker and somewhat stronger rather than back here in the thinner zone, as the Scorpion needle itself could inadvertently cut the suture. So when we load that, we like to load it here in the thicker zone and confirm it's within the notch itself, and then proceed with passage. Again, we want to make sure that the suture is being held in the top part of the cannula, so that we don't wrap around it and create a twist. So we've passed the loop end of the passing stitch through the labrum. And when we pass our repair suture it's going to invert the labrum back towards the articular cartilage. So if you see here we'll pass the suture through the loop. And we'll go white to white so that there's no overlap of the thicker portion of the suture inside the shuttle. That's important because we don't want to pull the thick portion through the construct, as it can impede the passage of the suture and make it a little bit more difficult here. As we tension down, you can see how we're inverting the labrum down back towards the joint, surface tension, how we like it. And then we just simply engage and cut. This is our third and final configuration the horizontal mattress or labral base repair configuration. It's important to lightly advance the anchor into the drill hole initially to make sure you're actually in the hole, and not inadvertently placing the anchor outside the hole. Once we have it in place, then we'll begin our passage. As in the previous two situations, we're going to introduce some slack into the system here so that we can lightly pull on one limb, preferably the looped limb, and then we have the non looped in right here. And just to confirm that we don't have any twists in the sutures themselves. So we're going to load the looped in into the Scorpion. We're going to pull the top sutures into the top portion of the cannula in order to prevent twisting. And it's important to understand that this bight is going to be a deep bight at the very back part of the labrum, in order to get directly at the junction of the labrum and the acetabular rim. The second stitch will be the repair stitch, as we call it, and this will go through the substance of the labrum in order to facilitate our horizontal mattress configuration. We'll load the white end of the repair suture through the loop. Double it back white on white and shuttle the suture through the internal mechanism of the anchor. And as you can see here, there's no circumferential cerclage, if you will, around the rim of the labrum, which is somewhat tension relieving and restores more of an anatomic repair with firm apposition of the labrum to the rim of the acetabulum. Again, we can introduce this into our drill hole in order to push against the anchor itself appropriately. Tension and then cut. As you can see from inside the joint, we have a simple stitch followed by another simple stitch, and then our labral base repair here. It's difficult to see because there's no circumferential wrapping of the labrum with the suture material itself. It's important to be able to have different types of repair configurations, because large labrums, for example, will tend to revert if you utilize a traditional standard simple stitch, as we did on the first demonstration. So the inverted simple stitch is able to prevent the labrum edge from everting. Again, it's important to have that labrum to cartilage contact. This first stitch that we use, the simple stitch in this situation was appropriate because the labrum wasn't over or undersized. Therefore, an anatomic repair was easily facilitated with that configuration. The third configuration, the labral base, allows us to prevent circumferential cerclage of the labrum, and theoretically and physiologically may allow better fixation without affecting the blood supply to the labrum itself.

Knotenloser SutureTak®-Fadenanker für die Hüfte

Der knotenlose PushLock-Anker zur Weichgewebsrekonstruktion wurde für die Verwendung bei arthroskopischer Stabilisierung des Hüftgelenks entwickelt. Das einzigartige zweiteilige Design ermöglicht eine kontrollierte intraoperative Fadenanspannung vor Verankerung des Ankers im Knochen, sodass eine exakte Geweberekonstruktion möglich ist. Er ist in bioresorbierbarem PLLA (Poly-L-Lactide Acid), BioComposite und nicht-resorbierbaren PEEK-Polymer erhältlich. Der PushLock ist jeweils in den Durchmessern 2.4 mm, 2.9 mm und 3.5 mm erhältlich. PEEK (Polyetheretherketon) weist eine hervorragende Festigkeit und Bioverträglichkeit auf. Das PushLock-Anker-Verbrauchsartikelset beinhaltet den Bohrer und die Bohrlehre, die für eine exakte Platzierung des Lochs am Pfannenrand erforderlich sind. Wiederverwendbare Bohrer und Bohrlehren sind ebenfalls in Hüftlänge erhältlich.

Travis G. Maak, MD (Salt Lake City, UT), demonstrates an acetabular labral repair using the 2.4 mm BioComposite Mini Hip PushLock® anchors with SutureTape to anatomically restore the suction seal of the hip joint. In this cadaveric demonstration, Dr. Maak outlines the steps for a single-cannula repair technique using the Hip Labral Scorpion™ suture passer to pass 3 circumferential sutures.

Acetabular Labral Repair Using the 2.4 mm BioComposite Mini Hip PushLock® Anchors

I'm viewing through the mid anterior portal with my instruments coming through the anterolateral portal. What we've done here is prepare the acetabular rim. Already we have a labral tear extending from the 12:00 to 3:00 position, with 3:00 being anterior and 12:00 being superior. As you can see, the labrum is peeled off the acetabular rim. We have labral junction damage. This is a labrum that is going to require repair. Interestingly, one of the problems with anchor placement is coming in the anterior position across the psoas recess. Psoas recess is anterior at the 3:00 position. What I do to ensure that I do not violate this recess is bring your Apollo wand at a 50 degree curve over the anterior rim. What you can see there is falling into the psoas recess. You can then define this with minimal dissection, so that when you put your anchor at the 230 3:00 position, you ensure you don't go over the top with violating the psoas recess. We will now proceed with instrumentation using a dowel portal, which we've identified here. The Dala portal is used to drill suture placement and anchor placement all in one. We'll start with drilling with a fishmouth guide at the anterior superior rim. This is the 12:00 anchor. The drill comes in. Oscillating. We're going to drill all holes at the same time. We then advance for our second hole. Go ahead. And then our final hole. Our anterior hole. Position again knowing where the psoas recess is. We're going to drill and avoid violation of that psoas recess. The drill can then be removed. And this the guide can then be utilized effectively as suction to remove the bone debris from the pre-drilled holes. This allows identification of these holes to easily place the PushLock anchors. Once this is done, the guide can be removed. The next step is placement of SutureTape Circumferentially. I prefer a circumferential labral repair. This allows me to appropriately control the labrum while minimizing labral eversion. At the 12:00 position the hole is identified, the labral Scorpion slides off the acetabular rim easily, visualizing anteriorly the sutures past, retrieved and through the portal. We are now ready for anchor placement. The biocomposite anchor can be easily loaded with the SutureTape, again without any suture retrieval. We are already through the dollar portal. Once this is anchored, it can be easily slipped down the dollar portal, ensuring orientation. With this position, the PushLock can also serve as a slight retractor. You can then see the anchor placed in the position. Check your tension. Ensure you like your tension. This can be easily identified. Once that is appropriately tensioned, it is then impacted into place. This has a laser line which allows appropriate positioning. Once that laser line is flush with the base of base of the anchor perfect. That can then be unscrewed. And with slight pulling that will slide right on out. The next step is the new Arthrex SutureTape cutter loads is an end loading system, and then easily slides down the portal and cuts perfectly as an end cut at the level where you pull in the sutures a little bit. A gentle suture pressure will allow ease of cutting at the level of the anchor. The first stitch is then placed. I prefer SutureTape as opposed to FiberWire, because it broadens the pressure on the labrum and minimizes potential labral cut through. If a patient has a traumatic event. Once this is done, the next suture can be placed again identifying the previous position, rolling over suture passage and retrieval. This can then be loaded up in the same suture technique fashion as before, lowing the biocomposite PushLock again without any suture retrieval or portal change. This is all performed through the Dalla portal, ensuring that the suture is appropriately positioned ready for placement. The biocomposite anchor is identified. Tension is confirmed and then the laser is mounted in for security at the laser line. Perfect. A small sound change can be used to confirm that the anchor is fully secured. Once this is removed, this is then loaded up as an end loading SutureTape cutter and then again through the Dalla portal. It's easily placed and cut. It's an end cut suture. Ease of passage. Minimal soft tissue injury. This can then be finally repeated for the third anchor. The third anchor position is identified. Again sliding off the acetabular rim to ensure you're not coming through bone. The suture is passed. Retrieved. As you can see, the biocomposite anchor is small, very minimal profile with excellent security. It is loaded simply with the SutureTape place through. This is then passed through the anchor. Suturetape passes very easily and is designed for this purpose specifically. Again slid down in the appropriate position, identifying the placement of the tape. Identifying the anchor pre-drilled position. It's then tensioned correctly and final security is confirmed. Mounting to the laser line. Perfect. Hearing the sound change confirms the appropriate position. It's then unscrewed. Removed. And then the final suture is cut. Flush. This completes the final labral repair. Again you can see the position of the 3:00 anchor. The over the top position. Adequate bone stock between the hole and the psoas recess to ensure that there is no psoas irritation because we confirm that position previously. Restoration of the Chondrolabral junction is confirmed. I prefer a circumferential labor repair for the reason that you get more labral tissue within your repair. It minimizes potential pull out of the suture and with the suture repair and the tensioning capabilities of the PushLock. Labral eversion is very, very hard to do. As a result, the suction seal is always restored even without a labral base stitch, and more labral tissue is incorporated, strengthening the repair. Once the labral repair is completed, traction can then be removed. The hip can be flexed. The suction seal is restored. You can see the sutures well. Repair the labral tear with adequate restoration of the entire suction seal from native labrum to native labrum, with a complete repair of the labral tear.

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.

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.

Carl H. Wierks, MD, (Grand Rapids, MI) demonstrates an acetabular labral repair using a toggle stitch configuration with a 2.4 mm Mini Hip PushLock® anchor. In this cadaveric demonstration, he uses the Hip Labral Scorpion™ suture passer for passing either a #0 FiberWire® suture or SutureTape in a unique configuration that allows for increased labral control, and helps facilitate proper tension to avoid eversion away from the femoral head.

Knotless Acetabular Labral Repair Using a Toggle Stitch Configuration with 2.4 mm Mini Hip PushLock® Anchors

My name is Karl. Works. I'm an orthopedic surgeon from Grand Rapids, Michigan. This is a video demonstrating a ToggleStitch technique using the 2.4mm peak PushLock anchors. We're in a right hip, and the scope is through the anterolateral portal. So you can see the femoral head off to the right. So let's recess here. So we're looking up at about the 12:00 position now. We have a slotted cannula coming in through a mid anterior portal. I've done an tuberoplasty in preparation of the labor repair. First thing we'll do here is drill three holes. So for the last stitch here we're going to use the SutureTape to allow to pass that through the more degenerative aspect of the labrum that allows more surface area. The advantage of the 2.4 PushLock compared to the 2.9 PushLock is a smaller diameter, so it allows for easier placement around the acetabulum, particularly medially and laterally, when where the acetabulum thins. There's also less depth of drilling, and so there's going to be less risk of puncturing the acetabulum during drilling and placement of the of the anchor. I typically prefer to drill all pre-drill all three holes, so we're loading a zero FiberWire here through the label Scorpion, and we're making the ends offset just slightly so that if the Scorpion does fray the suture when passing, that part won't be involved in the repair. So we'll secure the suture. And then this is coming in through the skid through the mid anterior portal. It's like a full thickness bite through the labrum at the contralateral junction. So right now we have the suture looped around the labrum. We have the two free ends here in my left hand and a loop in my right hand. And for the ToggleStitch we're going to pass just one of the limbs through the loop and then pull it down into the joint to tighten that around the labrum. And what happens is that loop will provide enough tension that it will allow us to roll the labrum. And again, you can see that hitch area. And I'll just pull a little bit on my left hand to roll that to the back of the labrum. But then that gives us enough control here. In this case I'm going to put more attention to my right hand now to do kind of kind of roll the labrum out or deflect it a little bit, and then I'll hold that tension as I pass the sutures through the eyelet of the anchor. So now we're bringing the anchor into the joint. After the suture, tales have been passed through the eyelet. What I wanted to show here is once you get the eyelet docked, what I can do is grab each suture tail independently. And I usually brace my thumbs here against the tines. But we still have some control here over how the labrum is going to sit. And then we can just secure it right there. And again, you don't see any drag with these 2.4 peak anchors. And I like using the O FiberWire for the same reason I was using heavier suture in the past, and I tended to see more drag with a bigger, larger gauge suture. So this is the labrum after three sutures with 2.4 PushLock for the demonstration. We're also going to do another SutureTape more laterally where there's an area more substantial labrum to show that rolling effect. Again, I made that drill pilot hole about as far lateral as I felt like I could, especially coming through this portal. The other option would be to switch portals come in through the anterolateral portal, but I can also cheat a little bit and put the suture in further laterally than where I drilled. The lateral Scorpion is nice here, just because it's minimally traumatic to the labral tissue, so we can pass the suture there at the junction with almost no footprint left, and does a nice job of just leaving the labral tissue intact and giving us a maximal amount of repair. So I have a loop, two independent sutures. I'm going to just grab one of the sutures here, pass it through the loop, and then pull that around the labrum, and I'll pull with my left hand to bring that crossover area to the back of the labrum. I like this view here when we're adjusting the tension. And it also shows here now that I can independently roll that labrum. And then I get that to where I like it and just hold that tension with my left hand as we pass the sutures through the eyelet of the anchor. Okay. So we have the 2.4 peak PushLock going in with SutureTape. So we have the SutureTape through the eyelet of the anchor. We can dock that eyelet islet into the pilot hole independently. Tension to. We still have a little bit of room to here to play with the deflection or rolling of the anchor. Okay, so once you're happy with the anchor placement, then it can be inserted without any further tightening of the suture. But the advantage of this toggle suture technique is that it allows for just a bit more fine tuning about how the labrum is positioned on the acetabular rim to try to prevent over deflection of the labrum. Knotless technique is nice, too. Just because there's no potential for the knots to come undone, you have less suture burden. So we've done a four anchor repair here. The peripheral sutures are the SutureTape, and then the two central anchors are an O FiberWire suture. But using the ToggleStitch technique, the advantage is that it allows one more layer of control in terms of how the labrum is sitting and allows more of an anatomic repair of the labrum. So we've restored the labrum back to an anatomic position, confirm that we've reestablished a suction seal, and then I would move on to addressing any Cam deformity in the peripheral compartment.

This animation of an acetabular labral repair in the hip demonstrates a simple stitch configuration using the 2.4 mm Mini Hip PushLock® anchor with SutureTape. The SutureTape is passed through a TRIM-IT™ custom hip cannula with a Hip Labral Scorpion™ suture passer, highlighting how this repair construct can be created quickly in a few simple steps.

Hip Labral Repair With 2.4 mm Mini Hip PushLock® Anchors

Hip labral repair with 2.4mm mini hip PushLock anchors. The anterolateral portal is established by inserting a spinal needle through the capsule and removing the inner stylet. The nitinol wire is then placed through the needle and the needle is removed from the joint. Next, a metal cannula is introduced over a cannulated obturator, and an arthroscope is inserted through the cannula and into the joint. The mid anterior portal is then established in a similar manner. A CapsuleCut blade is inserted through the mid anterior portal to create an inter portal capsulotomy between the anterolateral portal. A graduated switching stick is inserted into the joint, and the soft tissue distance is measured for a TRIM-IT custom hip cannula. The flexible cannula is then cut to the measured length and loaded into the adjustable obturator for insertion. A retractable hood burr is used to complete an acetabular plasty and prepare the rim for anchor placement. The sheath of the burr can be exposed to protect the capsular and labral tissue, or retracted to give better visibility. The round portion of a SutureTape is loaded into the top jaw of the hip labral Scorpion suture passer, and the back of the handle of the Scorpion is squeezed to load the suture into the notch of the needle. The Scorpion is used to pass the SutureTape around the labrum in a single step. The suture is disengaged from the Scorpion, and the two suture tails are loaded through the PushLock anchor eyelet. The suture. Tails are clamped with a hemostat, and a drill guide is placed along the acetabulum to create a pilot hole for anchor insertion. The drill guide is removed and the PushLock anchor is brought into the joint with the sutures under tension. The driver is advanced into the bone socket and the suture limbs are released. The orange cap is impacted with a mallet to bury the eyelet to the bottom of the bone socket, and additional tension is pulled if needed. The orange cap is removed once the barbed portion of the implant is flush with the bone, and the barbed anchor is impacted until the laser line is buried in the bone socket. The inserter handle is removed, and an open ended suture cutter is used to cut the sutures flush with the bone socket, and additional implants are inserted as needed.

Travis G. Maak, MD (Salt Lake City, UT), discusses managing hip pain in an elite speed skater. Dr. Maak presents his treatment rationale and labral repair technique using 2.4 mm Mini Hip PushLock® anchors with SutureTape to anatomically restore the suction seal of the hip joint.

Acetabular Labral Repair on a High-Level Athlete

Hello, my name is Travis Mack. I'm here to speak with you about hip pain in elite level athletes and how we can treat these patients better. This is a patient of mine who's a 20 year old female Olympic speed skater, complaining of right groin pain and lateral thigh pain with skating. She complained that she could not bend deeply at the groin to maximize her speeds going around turns, and that push off was very painful and limited her ability to explode. She reported pain with deep flexion and other activities, but primarily during her elite level speed skating. Examination revealed a negative stinchfield test, so minimal iliopsoas tendinitis. She had a positive fader and pain with anterior capsular stretching with external rotation, extension and abduction. She complained of no instability and had a negative Faber radiographic review, as demonstrated here, show a normal anterior acetabular coverage, lateral acetabular coverage, no evidence of dysplasia, and a small Cam deformity, as evidenced by the 45 degree done lateral, which can be seen on the bottom right. Mri evaluation also demonstrated an anterior-superior labral tear. This is identified both on the sagittal view on the top right, as well as the axial view on the bottom, with again normal chondral. Preservation. No evidence of chondral delamination or injury. She was managed for over a year by the Junior Olympic U.S. speed skating team. She had extensive rehab and Ms. limited. Her skating had very minimal improvement with these type of activities. She did interestingly have temporary improvement with her deep flexion, pain and aching when she got an Intra-articular ropivacaine injection. She was able to return to skating at higher levels when she was temporarily had temporary pain relief, but the pain returned. So this brings us to the different options which we have. Arthrex has given us a huge tool belt, which allows us to effectively address these types of problems in an efficient, effective and safe fashion. These are the instruments that I use primarily. Currently, the TRIM-IT Cannulas are my go to as far as saving the soft tissues and allow ease of passage of the instruments. I place one in my anterolateral portal and another in my distal anterolateral portal, with the camera, primarily in the mid anterior portal. The TRIM-IT cannulas allow you to utilize the different lengths to effectively treat different types of patients. Labral Scorpion I utilize with SutureTape to circumferentially repair the labrum and it is easy. It's efficient. The two for mini hip PushLock is my go to anchor. It's a knotless anchor. It's extremely small, which allows minimal injury to the Supraacetabular region. This comes in both a peek and Biocomposite option. So demonstrating the technique in this video you can see the labral injury. You can see the labral injury as well. The delamination identified as the labrum is prepared. Once the acetabulum is decorticated using the bur again minimal decortication. The drills for the PushLock are placed in just superior to the chondrolabral junction. The labral Scorpion allows a circumferential passage of the SutureTape, and then this is implanted and secured in the acetabular rim and a knotless fashion. One very important point, the Arthrex PushLock, allows the tensioning of the SutureTape to be performed prior to securing the suture. It does not over secure the labrum. It does not roll it back. Once this is done and the labrum repair is complete, I then address the cam deformity. This is done for me through a t capsulotomy. The Arthrex bur is utilized to allow an appropriate decompression of the cam in 360 degrees of view. This is again instrumenting through the dollar portal. Interestingly, the the bur, as you can see, has a hood on it which allows an appropriate protection of the soft tissue structures. Specifically in this case, the capsule which minimizes capsular trauma, preserves the soft tissue envelope and allows a good repair at the end without having to remove capsule during burring. Once the cam decompression is completed and a confirmed circumferentially through each view. Attention is then directed to the repair of the capsule. This is done for both the T and the inner portal limbs. I use a number two FiberWire in all aspects of this repair, which allows appropriate security, ease of passage, and final return of the capsule to its normal native state. X-rays identified here before. On the left. After. On the right you can see the decompression appropriately performed. Restoration of the femoral head neck junction is identified and confirmed. I use a live floral view as well as six specific individual views to confirm that appropriate decompression has been completed. After this surgery, this patient was back to speed skating. She feels much better. She still has a little anterior capsular tightness, which is not surprising at this point. But she's already improving. She's strengthening. She's training. She's back to what she's doing before, but with far less pain than she had previously. And we'll see if she makes it to the next Olympics. Thanks again for visualizing this today.

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