The CapsuleStitch suture passer arthroscopically passes suture to close the hip capsule through a single portal following hip arthroscopy procedures. Featuring a 2.3 mm outer diameter, the suture passer’s 70° bend is ideal for hip capsular closure. With 45 mm of suture throw and nitinol jaws that extend past the tip of the needle, a surgeon can push the PEEK tubing over the nitinol jaws to capture suture 7 mm from the end of the needle tip. The suture passer is compatible with 1.3 mm SutureTape, #2 FiberWire® suture, and LoopLoc™ knotless implants.

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Hip Next Generation in Soft-Tissue Repair and Reconstruction

Andrew E. Jimenez, MD (New Haven, CT), performs a closure of an interportal capsulotomy using the LoopLoc™ knotless implant and CapsuleStitch™ suture passer.

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Capsular Closure Surgical Technique Using the LoopLoc™ Knotless Implant CapsuleStitch™ Suture Passer

I'm Andrew Jimenez from New Haven, Connecticut. I'm here today to discuss hip capsular closure with you. We can see here that we've done already a hip arthroscopy with some intra-articular label repair. And now we're coming to the conclusion of the procedure. We're moving on to capsular closure. We were diligent during the hip arthroscopy procedure to preserve the acetabular leaflet here. And also maintaining a good capsular leaflet on the femoral side. That you can see here. And then our goal is to restore anatomy in this case. And we're going to be using the LoopLoc Knotless TensionLoc implant to do so. And usually I can get a good capsular closure with two sometimes three of those implants. But it's always going to be patient dependent. And you're able to achieve either a repair or a capsular application if necessary using this device. And you can see here we'll be passing the device through both the acetabular and the femoral leaflets here to aid with our closure. And you can see when we're done If we reduce the hip, we'll want the approximation just to restore the patient's native anatomy in this case. And now we'll be using our CapsuleStitch suture passer to pass two. Looped stitches through the capsule. This will aid us in using multiple LoopLoc implants for capsular closure. Sometimes if you deploy the first LoopLoc implant, it will close down the space for you to work. And so I usually prefer to pass a loop stitch first to aid with capsular closure. So we'll start coming in here on the acetabular side. We'll push through. Here. There we go. And now that we've passed through the acetabular side, we want to come across here and take a good bit of tissue from our femoral leaflet. So I'll puncture through and wiggle waggle through. And so you can see here we've passed one SutureTape length both through the acetabular and then subsequently the femoral limbs. There we're going to pass one more at the more lateral aspect of our capsulotomy to really close down this space nicely for us. So now we've passed a total of two SutureTape lengths through the capsule. We've set ourselves up now to use our Knotless LoopLoc implant for capsular closure. Here we've passed one medially and one laterally. And with that we should get a nice capsular approximation. So what we'll do here is I'll take a looped suture. Grasper. We're going to shuttle our second SutureTape link out through our dollar portal just to get it out of the way. So now we'll focus on our more anterior aspect of the capsule. Here we have our shuttling stitch placed there. We have a cannula here coming in through our mid interior portal. And now we'll be using our LoopLoc Knotless implant. To aid with closure. There's a couple of ways to use this. My preferred way is I like to clamp it to the drape. It helps to keep it secure. Won and also easily accessible when using the device for capsular closure. One thing to note for step one, we're going to be unraveling the suture. And you'll note there's two limbs of suture that pass through. When you go to unwind this, you want to make sure that you grab both limbs of suture and don't grab one independently. So what we'll do here is we'll pull on these two limbs together. It'll unravel through the card. And what you'll end up with is a passing suture, which will help you pass your first loop of the implant. So if you're passing this without using shuttling stitches like I have today, you can go ahead and just pass. Using this shuttling stitch first without doing this initial step for me, I like to do this first step to ensure that I have good passes through the capsule while it's still open. As you As you close the capsule down, you'll tend to lose space. It can make future passage a touch more difficult. So now that we have our shuttling stitch available to us, what we'll do is pass it through our loop of our patching stitch, and we'll shuttle this through. And once we have our shuttling stitch passed, all we have to do is pull on it. And that will pass the first loop of suture through. Now you can see here this is part of the reason why I like to keep this card close, because we need to have the open end of the loop visible through the cannula for passage of the second aspect of the card. So now we'll take a pair of scissors. Now we've passed the first limb of our LoopLoc implant through the capsule with our intra-articular view. Here you can see the first passage of the double loop. And on the outside you can see our card is set up here with our loop pass through our mid interior cannula. The next step is we're going to unwind suture number two. As you can see here on the card. And this will feed us a single limb of suture. Future. The next step is you're going to take this limit future. You're going to pass it through the open loop. And you'll notice in the LoopLoc implant here there's this passing flag. I like to pass a fair amount through and pinch it to ensure that it stays in place when we pass this. The other thing that I do is, as I go to pull this out, to ensure that the implant stays in place, I'll put my middle finger on the center of the device to hold the implant in place. So once we've done this, we're pretty well situated at this point. We can basically remove the sutures from the LoopLoc implant and we're in a nice position. We'll unclamp the LoopLoc card from the drape because we don't need it anymore. We'll end up with is two limbs of suture. And what I like to do is to even these sutures up and clamp them. Even so, you can see here, once we pass our suture number two through the card, we're going to have two have two uneven lengths of sutures. And we want to make sure that these sutures are even. What that'll do is it'll ensure that our interlocking loops are of the same length. That will help us get the interlocking loop in the center of our capsule repair. So what I'll do here is I'll pull this suture out to the same length, and I'll clamp it in place. Now, the next thing to notice is there's the center of the device which is here. You can see over here on the right there's one loop. And over here on the left there's another loop. I like to put my index finger within this interval because this establishes the middle of our implant. And we want to ensure that we pull equal tension on either side. So what we'll do now is I'll put my finger in the center of this implant, and we'll pull tension on it to deliver. The device into the hip joint. All right. So here you'll see that we have our first loop block passed through that cannula. And you can see the interlocking loop which we've secured in the middle of our capsule repair. Now this is a very important step. You want to make sure that interlocking loop stays within the center of the repair. Because if you pull too much tension on one of the stitches. It will displace the center of the LoopLoc device from the center of the pear, which is what you don't want. And what I'll do is a little trick that helps us ensure that that interlocking loop stays within the center of the repair. And that's the trick that I use using the Arthrex looped suture grasper. You can come in through the same anterior cannula, the same cannula your sutures are coming from. And what you want to do here is you want to grab each limb of this loop in your device. So I'll put the static arm into the first limb of suture. And I'll just rotate my hand to get the dynamic arm to grab the other end of the suture. And with this loop suture grasper locking those loops in place, we'll be able to tension the implant without displacing the center of the loop in one direction or another. What we'll do now is you can unclamp the sutures, and you want to tension each limb sequentially just a couple centimeters at a time. And you'll see as I pull on this, it'll lock the suture grasper back and forth, but it won't pull it through the capsule. Which is perfect. So we'll pull sequentially 12121212. And eventually what will happen is once you come down to the end of your tensioning, you'll notice that the implant is going to come and start to sit down onto the top of your repair. And what you want to do is get your suture grasper out of the way at this point. So what you're going to do here is you unlock it, just pull it back. Perfect. And straight out we'll do at this point is do a last couple pulls attention. And then I'll cut the ends of the suture and we'll do our final tensioning with the suture cutter. So we just have a suture cutter here. We're going to pass the two limbs through the suture cutter. We'll secure them in the basket. And what you can do now is slide the suture cutter down onto the top of the implant. We can do our final tensioning So what you'll see here is I'll take one limb and pull tension on it and take another limb and pull tension on that too. And you can go back and forth to set the tension of your implant. And when you're happy with that, you're going to engage the cutter and cut flush. The advantage of this is going to be that you're going to have a completely flat surface of your capsular closure implant, as opposed to having a big knot stack there, which in my opinion can cause inflammation, possible scar tissue. So here you can see our capsular closure using two knotless LoopLoc implants. We've got great approximation of our capsulotomy. We also have a knotless construct which doesn't have a knot stack present on top of the capsule. In my opinion, that stack can sometimes cause irritation, inflammation, formation in that area. And I think the knotless component of this helps to prevent that. If you want further information on this technique, you can consult the Arthroscopy Techniques article.

John Gualdoni (Arthrex Group Product Manager) gives a product demonstration and provides an overview of the features and benefits of the CapsuleStitch™ suture passer.

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CapsuleStitch™ Suture Passer Product Demonstration

I'm John Weldon, group product manager of hip arthroscopy at Arthrex, and today I'm going to run through a brief demonstration and some of the features and benefits of the CapsuleStitch Suture Passer, designed for closing the hip capsule at the end of a hip arthroscopy procedure. This device is a 2.3mm outer diameter device with a 70 degree bend on the end, designed just for hip capsule. There are two buttons on the handle that control the movement of nitinol jaws, and a peak tubing to pass and retrieve suture. There's a white sliding actuator you will depress down and forward to expel nitinol jaws to pass the suture underneath the capsule. When you're ready to lock the suture inside the nitinol jaws, push this black switch backwards to expose a PVC tubing over the top of the suture to remove the peak tubing from the nitinol jaws. Push this black switch forward. This black switch will remain in the forward position for the entirety of the procedure, except for when retrieving the suture and pulling it out of the capsule and out of the cannula. The first step is any suture you're using that has a glued tip or glued end of the suture. You want to ensure you cut that off before loading into the CapsuleStitch suture passer. This suture passer is compatible with number two FiberWire LoopLoc knotless implant as well as 1.3mm SutureTape. Again, any glued portion of the suture should be cut off before using the CapsuleStitch suture passer. So next to load the suture we'll push down on the white sliding actuator, ensuring that our black switch is in the forward position. We'll load the suture as close to the apex of those jaws as we can, and pull in the suture into the needle of the device. When this white sliding actuator is at the very back of the handle, you have 45mm of suture loaded from the tip of the needle inside the needle itself. So essentially, when you're passing the suture under the capsule, you'll be expelling 45mm of suture underneath the capsular leaflets to pass the suture through the capsule, take the suture, passer, and puncture through the first limb of the capsule. You'll next push the white sliding actuator down and forward to release the suture underneath the capsule. Once the suture is released, you'll push down and pull backward on the white sliding actuator to pull the jaws back into the needle. You'll pull the needle out of the capsule and move to your second limb of capsule. You'll then puncture through that leaflet of capsule, and when you're ready to grasp the suture, push down on the white sliding actuator and forward to get the suture inside the nitinol jaws. Once the suture is inside the jaws, push the black switch backward to expose that peak tubing over top of the suture. I will note there are seven millimeters of extra reach with this suture passer. So your jaws stick out seven millimeters from the end of the needle. And that peak tubing can close over top of the sutures seven millimeters from the end of that needle. Once the suture is inside the nitinol jaws and the PVC tubing is over top of the nitinol jaws, push down and pull backward on the white sliding actuator to pull the suture into the bend of the needle. It's important to keep the suture right at that bend, as you're pulling it out of the leaflet of the capsule and out of the cannula to ensure suture retention strength once you have it loaded in the jaws. Pull the device out of the capsule and out of the cannula to dislodge the suture from the CapsuleStitch suture. Passer. Push down and forward on the white sliding actuator, and then push the black. Switch forward to expose nitinol jaws and remove your suture for subsequent tying and closure. I will note when retrieving suture from underneath the capsule to only grab one limb of suture, and not two, as only one will fit inside the nitinol jaws with the peak tubing over top of it. Next, you'll tie your sutures and pass as many sutures as needed to repair your hip capsule at the end of the procedure. Thank you for your time.

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Knotless Hip Capsular Closure Using the LoopLoc™ Knotless Implant and CapsuleStitch™ Suture Passer

A step-by-step demonstration of how a product would (or could) be used in a surgical technique.

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Hip Capsular Closure Using The LoopLoc™ Knotless Implant and the CapsuleStitch™ Suture Passer

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Scope This Out - Volume 24, Number 1

Hip Capsular Closure Using the CapsuleStitch™ Suture Passer

This animation demonstrates an arthroscopic hip capsular closure using the CapsuleStitch™ suture passer with SutureTape.

A general overview including the relevant steps of an Arthrex surgical technique. These animations always include a voice-over explaining the process.

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CapsuleStitch™ Suture Passer

Outside the arthroscopic cannula expose the nitinol jaws of the CapsuleStitch suture passer by, pushing the white sliding actuator down and forward towards the shaft of the device. Once the jaws are exposed, cut the glued portion of the suture and load approximately five millimeters into the nitinol jaw of the suture. Passer. Push down and then pull the white sliding actuator backward to pull the suture into the needle of the device. Place the CapsuleStitch suture. Passer through the distal anterolateral accessory portal to pass suture through the most distal medial aspect of the T capsulotomy. Push the suture underneath the capsule and into the peripheral space by pushing the white sliding actuator down and forward. Once the suture is released from the jaws. Push down and pull the white sliding actuator backward so it's loaded back into the needle. Remove the needle from the capsular leaflet with the device still in the capsular space. Push it through the distal lateral capsular leaflet to retrieve the past suture. Push the white sliding actuator down and forward so the nitinol jaws are located next to the suture. Once the suture is loaded into the nitinol jaws, pull the black switch backward to capture the suture in the peak tubing. Push down and pull the white sliding actuator to its original position. Keep pressure on the white sliding actuator as the device is withdrawn from the cannula, to ensure the suture holds well. Once the suture passer is outside of the arthroscopic cannula, release the suture by pushing the white sliding actuator forward, exposing the peak tubing, and then push the black switch forward to expose the nitinol jaws in the suture. Tie and cut the suture tails and repeat these steps for the additional stitches.

Ajay C. Lall, MD (Paramus, NJ), performs a cadaveric demonstration of closing an interportal capsulotomy with the CapsuleStitch™ suture passer and SutureTape.&nbsp;

Capsular Closure Using the CapsuleStitch™ Suture Passer and SutureTape

Hi there, this is doctor AJ lol from LOL orthopedics. This is the CapsuleStitch instrument shown here. And what this is going to be utilized for is for passing sutures through capsule, specifically in the hip. This instrument is pretty unique. It does come with a 70 degree bend at the tip of the instrument itself. It's got a reinforced stiffened shaft here. To load the instrument, you're going to simply take the instrument in one hand, you'll take your suture in the other. And what we'll do is we'll we'll open the jaws with the thumb. We'll place the suture inside the jaws retract back and pull. So now, if we're at the portion of the case where you have more friction anticipated because the suture is within a soft tissue, notably the capsule, this is no different from our use. We're going to simply deploy the jaws, past the suture, through the jaws, and then take the black switch and pass up. We'll pull this back and pull the suture through the through the tissue. That extra friction will prevent the suture from pulling out of your instrument so you can see it's pretty robust. It's not going anywhere, so you'll have plenty of tension when trying to pull. So now we are back in the hip here. And what we've done is positioned two cannulas in the mid anterior portal as well as the Dalla portal. And these are going to be our working cannulas to pass our suture through the capsule with the CapsuleStitch. So to load suture within the CapsuleStitch, what we're going to do is simply deploy the jaws like we showed you before. We're going to bring the suture in, pull back, and now it's loaded. So my preferred technique is to come through the proximal cannula within the goals of, of entering the proximal leaflet of the capsule. And we've prepared the capsule here. So you have distal leaflet there and proximal leaflet here. So we're going to take care to avoid the Directors. We're going to then pierce the capsule and wiggle waggle our way through. You can see the sutures there. We want to stay out of that. And once we are free and clear of that area, we can then deploy our suture as seen here. And we'll pull back the actual jaws of the device. So now that we've passed the suture limb through the proximal leaflet, what I prefer to do is come out through the cannula, bring my instrument in, and we will then address the depth and the location of the distal bite based off the patient's instability or stiffness. If I wanted to placate the case I would then move more distal and medial. Whereas in more of a capsule or side to side repair would be simply directly across from where we entered the proximal leaflet. So in this case, for demonstration purposes we'll do a side to side repair. We'll simply take the CapsuleStitch penetrate the capsule distally. We'll wiggle waggle our way up to the joint line. Once we are through, we will then deploy the jaws around the suture. And now, because we anticipate more friction when we pull the suture out, we will then take the black switch here, deploy it so it provides this added stability to the suture will then retract the white sliding button and then simply pull the suture out of the cannula. Once the suture is out, we'll take another set of sutures and the CapsuleStitch one more time we'll bring another one in again. It's been loaded. We'll go through the proximal cannula again. Care to avoid the rectus? We'll stay beneath that. And on top of the capsule, we'll deploy our suture. When you wiggle waggle a little bit, that's when you'll find that it exits the actual teeth. We'll then come through the distal cannula. We'll sort of set ourselves up for success by slightly grasping the suture and bringing it to an area that we know we will be eventually coming through. Just a general vicinity is sufficient, so then we'll go again through the distal leaflet penetrate. And we know where we're going to be in this region. So here we are. We will then deploy the jaws. And again we want to pull back on the black switch which will deploy the peak tubing, adding that friction will pull back on the entire mechanism and hold it toward the back of the CapsuleStitch. And then we will pull the suture out and we'll go and take our suture retriever. We'll come up and get the proximal end of the suture. Pull that out. And now that's our number two. And you can repeat these steps as many times as you want. So you know, one, two, six. Whatever your heart's desire. You're putting in sutures that you're going to then be tying. And we have a little bit of obliquity to them, which is going to provide us a little bit of an imbrication and shift. We just repeat the steps again. So now what we're going to do is take our suture retriever, and we're going to go and retrieve our first set of sutures. So we'll take the proximal limb and the distal limb which is right here. Now what we've also published on with myself and Ben Dohm is we published an interesting take on how we grasp these sutures. We want to perform what's called the X grab. What that allows us to do is to know that when we are tying the sutures, they're going to be proximal limb is the post in every case for these suture tying. But right here, when I pull the actual retriever out, I know what is proximal just by the way that it exits the cannula. So I know that this is my proximal limb so I can save time knowing which one is the post, and that's the one that I'm going to shorten. So without even looking up, I can know that this is proximal leaflet here. As you can see, I'm pulling on it now because of the X grab and it's arthroscopy techniques article, which explains the utility of that and saving steps in the operating room. We'll then do what's called the Alabama slider. I'd like to do a b I learned this in Birmingham, Alabama. Lyle Cane Jeff Dugas Benton emblem simply AB and then pass the knot down. I'll take a knot pusher. We'll load this into our knot pusher. So there's your knot and we're simply tying that leaflet down. You can see how we've brought that capsule together. And we'll pass this knot. It's locked and then just tie. So we did AB and then we'll do four more half hitches you can see are not coming down to the joint, and we then will bring our sutures into our closed cutter, bring that down and cut. And so we just repeat the steps two more times and we'll do that quickly. So we've completed our capsular plication in this case with a total of three SutureTape sutures. We've utilized the CapsuleStitch suture passer with ease. And again, you can see how nice and close even in a cadaveric specimen. We've taken care to avoid any kind of injury to the rectus. We've got pre capsular fat still visible above us obviously some some low hanging leaflets of tissue from the cadaver. But for the most part we have a really robust capsular repair. Three sutures in total. This came out really nicely and very very easy to use especially with the CapsuleStitch.

CapsuleStitch™ Suture Passer

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Capsular Closure Surgical Technique Using the LoopLoc™ Knotless Implant CapsuleStitch™ Suture Passer

Capsular Closure Using the CapsuleStitch™ Suture Passer and SutureTape

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CapsuleStitch™ Suture Passer

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Hip Capsular Closure Using The LoopLoc™ Knotless Implant and the CapsuleStitch™ Suture Passer

Hip Capsular Closure Using the CapsuleStitch™ Suture Passer

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Knotless Hip Capsular Closure Using the LoopLoc™ Knotless Implant and CapsuleStitch™ Suture Passer

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Hip Next Generation in Soft-Tissue Repair and Reconstruction

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CapsuleStitch™ Suture Passer Product Demonstration

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Scope This Out - Volume 24, Number 1

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