The Hip Arthroscopy Accessories Instrument Set contains hip-specific instrumentation to aid in suture passing and disposable cannula insertion associated with hip arthroscopy procedures. This set includes the Hip Labral Scorpion™ and CapsuleClose Scorpion™ suture passers as well as the insertion instrumentation for the&nbsp;Trim-It™ Custom Hip Cannula. The Extended Hip Length Drill Guides for the Short 2.9 mm Hip PushLock®&nbsp;implants and associated drill bits are included with a large pin mat area to hold additional accessories. These drill guides have been designed specifically for the hip to accommodate all patient sizes and portals necessary to perform arthroscopic procedures of the hip. Additionally, there is a Switching Stick Inserter to aid in the insertion of Switching Sticks into the arthroscopic and endoscopic spaces of the hip. All components in this instrument set can be purchased separately.

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Postless Hip Arthroscopy Using the Hip Distraction System

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Hip Arthroscopy Accessories Set (AR-6518S)

Benton A. Emblom, MD, (Birmingham, AL) presents his technique and rationale for performing capsular closure at the end of a hip arthroscopy procedure. In this video presentation, he outlines the steps for passing a running suture to close an interportal capsulotomy using the Hip Labral Scorpion™ and CapsuleClose Scorpion™ suture passers.

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Capsular Management and Closure Technique Pearls

So our capsulotomy is in general, some people do apply them and some people don't. I would say that most people that do hip arthroscopy utilize a capsulotomy, and the principles for a capsulotomy, in my opinion, are for improved visualization and maneuverability. Without maneuverability, you can't see. If you can't see, you can't make the appropriate diagnosis. And if you can't make the appropriate diagnosis, you can't provide the appropriate treatment in terms of different Capsulotomy is that area right there that you see with the yellow triangle is typically the zone where we typically apply most of these capsulotomy. The simple portal expansion is what I like to do when I get started. And that's basically with either a radiofrequency ablation or a small capsular knife. Simply just enlarge the capsule portals just so that you can see and maneuver enough to make an assessment of what's going on, then followed by capsular elevation techniques, you can use these angled ones to elevate the acetabular leaf of the capsule up off the acetabular rim itself, followed by intra portal capsulotomy and extended portal capsulotomy. Excuse me, extended inner portal capsulotomy in the T-type intertrochanteric capsulotomy that's oftentimes used to gain significant lateral access. The capsulotomy in general is usually performed sharply and or with some form of electrocautery. The current instruments that we have to to access in terms of capsular management starts with basic capsular blades, radiofrequency ablation, or straight and angled labral Scorpion suture passers, as well as the capsular Scorpion, suture passers and heaven forbid, the need for an ArthroFLEX patch if you get into too much capsular deficiency. So what does the current literature suggest? It was published in arthroscopy in 2015 that the influence of capsular repair versus unrepaired capsulotomy on two year follow up really didn't show any significant difference in outcomes, but it also showed that there was no significant poor outcomes after the capsule was repaired. And in 2016, it did show that patients that had failed arthroscopic surgery and subsequent instability had significant improvements after the capsule capsule was repaired at revision. Furthermore, in ajsm in 2016, a biomechanical study demonstrated that there were significant improvements in terms of capsule strength and integrity when you use three sutures compared to one. There was no significant statistical differences between 2 and 3, but the maximum rigidity and stability was accomplished with three. It also demonstrated that 36 degrees of external rotation was kind of the failure point when most of these capsule repairs would fail. So basic capsule management techniques. I'll show a video here. This is a right hip. You can see a capsular knife introduced into the mid anterior portal. And we're going to establish a basic inter portal capsulotomy here okay. This is viewing from the anterolateral portal. The capsular knife working towards the camera. And then when I make these, I like to take the knife and then deviate it away from the acetabulum. So when you reach the point of the scope, you have one of two ways to go. You either can go towards the acetabulum or away from it. And it's obviously counterintuitive that you want to go away from it to preserve your acetabular relief. This is a 50 degree arthroscopic radiofrequency ablator that enables you to get up under the acetabular leaf and elevate the soft tissue, maximizing your exposure of the acetabular rim, assessing the acetabular labrum, and maintaining and preserving your acetabular leaflet for further repair. Here you can see a complete exposure of the acetabulum. The the capsule has not been violated here. I'll oftentimes place sutures within the acetabular leaflet. Here I'm using the Arthrex capsule close Scorpion. Just from an angular standpoint, it provides an easy access in terms of angle. And then I'll retrieve these typically out of a superior accessory portal. And then I can completely elevate the capsule up off the acetabulum, enabling complete exposure of the acetabular rim on the femoral side. We'll use the same Scorpion and typically pass 2 to 3 sutures within the femoral leaflet, and then pull those out through separate accessory portals in a divergent pattern so you can pull them out all through the same portal. But it helps to pull those out divergently so that you get a greater spread and further elevation of the capsule to improve visualization. This allows you to see typically as medial or excuse me, as lateral as you need to see in order to perform an appropriate thermoplasty with the aid of rotation and fluoro. And if you need to exchange back to a 70 degree scope, if you're using a 30 degree scope in this position, you're able to do that and look up under the capsule as you elevate it. Capsular closure techniques are numerous. Personally my technique I like to use the Arthrex Scorpion devices. I've started using both of them, the labral Scorpion and the capsular Scorpion. I think the most important concept here is to completely debris any fallen tissue that's going to be in front of you, limiting visualization to allow easy suture management and passage. I would compare this to doing a bursectomy at the time of doing a rotator cuff repair. You can see here we've got significant capsular exposure. Obviously there's the femoral leaflet. We're going to come in with our radiofrequency ablator and finish off a couple more of these bands. We're not cutting more capsule. We're simply removing some deep layers of fascia up under the TfL and some of the overlying structures, including part of the indirect head of the rectus. Here we're going to complete a leaflet, so we'll be able to appropriately grasp the acetabular leaf of the capsule. This will allow for better mobilization and decrease failure in terms of trying to pass that Scorpion device through thick, tough tissue. So once we come in here and have this fully exposed, then we'll insert a cannula back down through the anterior to mid anterior portal. And as you can see here I'm using the labral Scorpion because I feel like I can get a much better bite on the capsule than I can with the capsular Scorpion on the acetabular side of the repair. Once I pass the first stitch with the labral Scorpion, I'll follow that with a passage using the capsular Scorpion. Based on that angle, you can tend to get the capsular tissue better with the capsular Scorpion on the femoral side. I'll follow that back with another pass. This is a figure of eight technique on the acetabular side, utilizing the labral Scorpion, again followed by a passage with the capsular Scorpion on the femoral side. This is a non-absorbable suture. It slides. You can tie this easily with standard arthroscopic knot tying techniques. You see here you get good apposition of the capsular leaflets. I feel like you get better tension relief by using a figure of eight type stitch as compared to using some sort of mattress stitch on a skin closure. You've seen these cases before, where the acetabular plasty and the thermoplasty causes some capsular trauma, and the pull out strength sometimes can be degraded. In terms of the capsule that you're working with here, you get a figure of eight type construct with much better soft tissue handling. Here's the same process. We have labral Scorpion followed by capsular Scorpion, followed by labral Scorpion, and then finished up with another pass of the capsular Scorpion. The one pearl, I will tell you, in addition to the technique alone, is you have to really be careful and pay attention to where your sutures are, because sometimes they will inherently end up on the wrong side of the suture. So you've got to tease those out with a loop grasper or any type of Suture grasping device just to maintain normal orientation. Then we'll tie these and secure these just like we did the previous. Now, if you if you recollect when I showed the first part of this closure technique, the anterior aspect of the capsule, I was unable to get a really good bite with the labral Scorpion. So I'll go back to that after I've already tensioned the capsule, and the capsule is no longer running away from me, and I'll be able to close this last portion of the anterior portion of the capsule utilizing the same technique with labrum capsule, labrum, capsule, I'm able to perform a figure of eight closure provided arthroscopic knot tying technique, and get this closed with three sutures, but in essence are equivalent to eight excuse me, six sutures with a simple fashion you can see. Here we come over and look right on top of the capsular stitch, and you can see a nice crossover figure of eight stitch, enabling a solid repair. So in conclusion, hip capsule anatomy is complex, and although the capsule gets most of the attention in terms of managing instability and postoperative complications, there are multiple factors that contribute to overall stability. The literature is not definitive yet on capsular closure. However, it has been shown that features or excuse me failures revised with closure have significantly better outcomes. We do know that capsular closure has been shown at two year follow up, not to cause any negative effects. That failure is typically associated with the lack of closure, have significant improvement in outcomes when closed, and 2 to 3 sutures is effective in terms of maintaining adequate capsular closure. So common sense alone would tell you that you should close the capsule if you open it. Lastly, there are a handful of tools that we see that Arthrex provides, fortunately, that allow us to respect the capsular anatomy and facilitate sound repairs. Thank you.

John Gualdoni (Arthrex® Product Manager) discusses the latest technology advancements and innovations in hip joint preservation products. He highlights the features and benefits of some of the recently released hip products including the Hip Labral Scorpion™ suture passer, CapsuleClose Scorpion™ suture passer, TRIM-IT™ custom hip cannula and the CapsuleCut™ blades.

Hip Preservation Product Updates

I want to start off with the first slide just showing sort of what I think is important to know here at Arthrex is that we really offer a full, comprehensive product offering everything from patient positioning to joint access all the way to tracking outcomes in SOS. If you look back, you know, roughly 5 or 6 years ago in 2011, we had some shoulder stuff we were using in the hip. We were making it work. We had a distraction system that was okay at best. And as you look to 2017, kind of where we've gone and where we're going again, we've got that full offering of products from patient positioning, hip distraction system all the way up to curve burst shavers, small implants dedicated just for the hip, and new Knotless technology that I think is very exciting. Patient positioning and hip access some updates. So we've got a very nice hip distraction system table. We've got it outside as well if you want to go through a demo. This system is designed to fit on most beds via some adapters. You've got easy controls for your gross traction and your fine traction. You can also manipulate the hip very easily by some distal controls on the end there. It's a It's a very fluid, very dynamic system. And you can also detach the boot very simply to do a full dynamic range of motion check at the end of your cam. Osteochondral Plasty. Additionally, the perineal post and pad can also be removed. So we've we've put together this nice system. It's easy to set up sets up in roughly seven steps. So it's easy for the staff for your nursing staff as well as for you, the surgeon. Very intuitive with the easily marked controls to manipulate the foot. Additionally, we've updated our hip access instrumentation, so we've just released the new updated hip Synergy.net. We've got a quick connect bridge system, we've got C-mount and IP scopes. There's slightly longer than traditional scopes, so there are 200 millimeter working length. They're not excessively long. So some of the competitive products are roughly 300mm. These are 200mm. So they're long enough for pretty much every procedure you're going to do or encounter in the hip. We've dulled down the ends of these as best we could to make them as atraumatic when entering the joint space as possible, and it's a quick connect bridge. Now, you can you can easily push a button that will connect to the scope as well as to the cannula, so you can easily bounce back and forth between your two portals very quickly, very effectively, very simply, between the two portals that you're maneuvering through. And additionally, again, the traumatic nature of the cannula, we've changed the tip geometry to these. We've removed and made these non fenestrated to make them as atraumatic on the cartilage surface when you're entering the joint space. Additionally, some different hip blades we offer we offer a retractable knife. So this is a left hip specimen anterior lateral with the scope. We're coming in the mid anterior portal. You can see we're going over top of a guidewire. So this blade allows you to safely put a blunt object into the joint space. There's a safety tab on the back of this device. And when you pull that off it exposes the black button. You'll then push that down and pull it up approximately. And that will actually move the sheath. It doesn't move the blade into the joint, it actually moves the sheath out of the capsule. So now your blade is exposed, you can simply do a very reproducible capsulotomy and then you then you can put the sheath back over top of your through your soft tissues, and then bring the device out of the joint. Flip portals and very safely do a capsulotomy. Additionally, we've seen the need for a more reinforced capsulotomy blade, so we just are in the process of launching the CapsuleCut blade. This is a very stout, straight double radius blade, so it's got a very sharp edge on each side, and you can simply cut through the thick iliofemoral ligament and also do a very effective T capsulotomy if you prefer that. We've got a version with a handle on the back end there that's all disposable. We also have a reusable handle for more economical purposes. But again, we're very excited to have this product. You can really go from taking a capsulotomy down from a couple of minutes. You can do this now in seconds. You can simply just push along the capsular tissue and it will cut it like a butter knife right through the tissue. You guys saw this yesterday. The knotless SutureTak. There's a lot of indications for this also in use in the hip. And you can see here this is paired with our hip label Scorpion. The nice thing with this anchor in the hip is it allows you to control that tension very simply and very effectively to avoid any labral reversion away from the femoral head. You'll see You'll see this presented later on this morning as well. But I think, you know, pay attention to the different pearls and techniques for this. There's a lot of unique things to this anchor that you can use for the hips specifically, aside from being a great construct in the shoulder as well. Different suture passers. We have a hip labral Scorpion. This is a fast pass. Scorpion. It allows you to effectively pass a suture from the extra articular side, from where your anchor is placed into the joint space and out in one simple pass. It will fit through an eight and a quarter cannula, and it's designed to go into the joint space so that angle is such that it will shoot the needle into the joint away from the femoral head, and follow your acetabular concavity. If you look here and compare some of the competitive products in the market. So let's say A15 diameter SutureLasso if you look at the area of that, if you do a cross section, just take the area of that metal surface when you cut or what's actually going through the tissue, it's roughly 1.77mm squared. If you take the actual needle that's going through the labral tissue and the hip labral Scorpion, and you cut that into a surface area, you get roughly 0.43mm Millimeters squared, so it's roughly four times smaller than most devices that are on the market. So it really does leave the smallest hole going through your tissue. So the jaws. Again will fit through an eight and a quarter cannula. A nice angle a nice curve to go into the joint. And that needle is is really really small to give you a nice or maintain that suction seal effect in the hip joint to play off the success with that product. We've also launched the capsule closed Scorpion. This device is like any other Scorpion very simple, very ergonomic to use. You simply squeeze the back of your handle to push a needle through that lower jaw. You load the suture in that distal jaw the same way for the first and the second pass. So it gives you a 4.5mm bite of tissue from where your capsulotomy was made for every pass. So very reproducible, very simple, very straightforward to, to use and load. So here's just a quick video showing sort of a cadaver use. So again we're doing a this is a right hip. We're looking at the proximal limb here. So you come down put that lower jaw underneath your tissue. You compress the tissue with that front trigger squeeze to push the needle through the the tissue. You grab the stitch, come out, disengage the suture, load the opposite side. And then we call it kind of walking the dog. So you pull the limb you've already passed and push the device into the joint to avoid any tangles. Flip your jaws and go in the distal limb. Now you can effectively close off within a mattress suture and tie that stitch and pass as many sutures as you would like for both the inner portal and a t Capsulotomy. Looking at different cannula options, we've recently launched the TRIM-IT hip specific cannula. This is designed just for the hip, and you can see here it's a very simple insertion mechanism. So you measure with a calibrated switching stick. You cut the cannula down to the desired length. You simply adjust an obturator and then insert the cannula into the joint space. You can see here in this video demonstration. The cannula itself is flexible. It's a polyvinyl chloride material. So it's very flexible and very atraumatic on the cartilage. It's easy to see through. So again, aside from being able to trim it down to size to custom fit to your patient, again, it's going to be very atraumatic on the articular surfaces and very simple and straightforward to insert. There's proximal threads, so they hold exceptionally well in the soft tissues of the hip. And again you can fit larger and curved instruments down there very easily and very effectively through your soft tissues to the hip joint. So I like to show this video. This compares sort of our polycarbonate, our hard plastic cannulas. If you look here this is a same incision for both of these videos. But the polycarbonate cannula just backs out. If I just pull those threads even though it's fully threaded. I've done a large capsulotomy on this, this patient, you'll pull out the cannula every time. And if you look here, we've increased the thread pitch as well as the diameter on these soft cannulas. And they hold exceptionally well in the soft tissues. So no more do you have to have your patient or excuse me, your PA or your surgical assistant hold the cannula as you're coming in and out with instruments. You can simply leave this cannula in and not worry about it as you're moving on with your procedure. So again, very, very effective for the hip joint itself. We've also launched a new set that includes all these instruments in it. So both Scorpion TRIM-IT cannula instrumentation, the CapsuleCut blade handle, as well as some longer drill guides for our two nine PushLock that are designed just for the hip specifically.

Hip Arthroscopy Accessories Set

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Surgical Technique Guides (1)

Postless Hip Arthroscopy Using the Hip Distraction System

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Capsular Management and Closure Technique Pearls

Hip Preservation Product Updates

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Hip Arthroscopy Accessories Set (AR-6518S)

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AR-6518S