Place sutures in the labrum using a number of Arthrex suture-passing devices and fixate the labrum to the 
acetabulum using circumferential or labral base stitch techniques. Insert SutureTak® and FiberTak® suture anchors into the acetabulum before passing suture through and around the labrum. PushLock® suture anchors require the suture to be passed through and around the labrum prior to inserting the anchor into the acetabulum.

Procedure

Achieve labral fixation by placing sutures through the labrum in simple or labral base stitch configurations using any Arthrex suture passer. Standard and Knotless SutureTak® and FiberTak® anchors should be placed prior to passing the repair suture, while PushLock® anchors should be placed after passing the repair suture.

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Hip Next Generation in Soft-Tissue Repair and Reconstruction

Labral Repair Using the 2.4 mm Knotless Hip SutureTak®  Anchor

This animation demonstrates an acetabular labral repair with a 2.4 mm Knotless Hip SutureTak® suture anchor and a SwiftStitch™ suture passer. The low-profile repair construct can be tensioned to avoid labral eversion away from the femoral head and maintain the suction seal of the hip joint.

video

Hip Labral Repair With 2.4 mm Knotless Hip SutureTak® Anchors and SwiftStitch™ Passer: Simple Stitch

Hip labral repair with 2.4mm knotless hip SutureTak anchors and SwiftStitch suture passer simple stitch insert a 4.0mm round retractable hood burr through a TRIM-IT custom hip cannula and perform an acetabular plasty. Insert a curved SutureTak drill guide through the cannula and place it along the acetabular rim. Use a 1.9mm flexible drill bit to create a socket for anchor insertion. Drilling options include straight 12, 16, and 20 degree angles. Insert a 2.4mm knotless hip SutureTak through the drill guide. Push the anchor in by hand to engage the tip of the anchor in the socket. Impact the anchor until the positive stop on the back of the drill guide. Remove the suture release tab. Remove the drill guide and anchor inserter from the cannula. Load approximately ten millimeters of the repair suture into the jaws of the SwiftStitch suture. Passer. Retropasser use the SwiftStitch to pass the suture through the base of the labrum and release it into the joint space. Retrieve the suture in the SwiftStitch and pull it outside of the cannula, removing all slack. Outside the cannula. Load the repair suture through the loop of the shuttle suture and crease it at the blue mark. Pull the SutureTape end of the shuttle suture to pass the repair suture back through the anchor. Pull the repair suture to the desired tension. Use a mini suture cutter to cut the suture flush with the bone. Insert subsequent anchors as needed to complete the labral repair.

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.

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.

This animation features the 1.8 mm Knotless Hip FiberTak® soft anchor used for an acetabular labral repair and outlines the steps for implanting and using this novel tensionable knotless technology.

Hip Labral Repair Using the 1.8 Knotless Hip FiberTak® Anchor and a Simple Stitch

Hip label repair with a knotless hip FiberTak anchor simple stitch. Use a retractable hood burr to complete an AC tuberoplasty and prepare the rim for anchor placement. Place a 20 degree curved drill guide on the acetabular rim, and use a flexible drill pin to create a pilot hole for anchor insertion. Insert a knotless hip FiberTak anchor through the drill guide and impact the handle by hand to a positive stop. Initially, set the anchor in bone by grasping the sutures and pulling the handle proximally. Remove the handle and pull all of the sutures to confirm the anchor is adequately set in bone. Remove the drill guide from the cannula and load a short tale of the white portion of the repair suture into the jaws of the SwiftStitch suture. Passer. Advance the SwiftStitch suture. Passer down the cannula and push it through the base of the labrum. Depress the black button and push it forward to release the suture into the joint, remove the suture, passer from the labrum and retrieve the repair suture from the joint, and pull the slack out through the cannula outside of the cannula. Pass the white end of the repair suture through the loop of the shuttle suture, and pull the non looped end of the shuttle suture until resistance is felt. Gently pull 3 to 4 light tugs to pass the repair suture back through the anchor sheath. Pull on the repair suture to get the initial tension outside of the cannula. Load the repair suture into the suture tensioner cutter for final tensioning and cutting. Insert subsequent anchors to complete the labral repair.

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Scientific Updates

Acetabular Labral Reconstruction Scientific Update

Labral Fixation

SwiftStitch Suture Passer, Hip Length, Crescent

SwiftStitch, Fadeneinzugshilfe, hüftlang, halbmondförmig

SwiftStitch Suture Passer, Hip Length, Crescent

Pasador de sutura SwiftStitch paraartroscopia de cadera, crescéntrico

PASSADOR DE SUTURA SWIFTSTITCH , QUADRIL, CRESCENTE

Child (D)

Suture passing is made easy with the wide variety of instruments from Arthrex, including SwiftStitch™, SutureLasso™, BirdBeak®, Penetrator™, Hip Labral Scorpion™ and CapsuleClose Scorpion™ suture passers.

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

Acetabular Labral Repair

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

This animation features the 1.8 Knotless Hip FiberTak® anchor used with a SwiftStitch™ suture passer to create a labral base stitch through the acetabular labrum.

Hip Labral Repair Using the 1.8 Knotless Hip FiberTak® Anchor and a Labral Base Stitch

Hip label repair with the 1.8mm Knotless hip FiberTak anchor labral base stitch. Use a retractable hood bur to complete an acetabular plasty and prepare the rim for anchor placement. Place a 20 degree curved drill guide on the acetabular rim, and use a flexible drill pin to create a pilot hole for anchor insertion. Insert a knotless hip FiberTak anchor through the drill guide and impact the handle by hand to a positive stop. Initially, set the anchor in bone by grasping the sutures and pulling the handle proximally. Remove the handle and pull all of the sutures to confirm the anchor is adequately set in bone. Remove the drill guide from the cannula and load a short tale of the white portion of the repair suture into the jaws of the SwiftStitch suture. Passer. Advance the SwiftStitch suture. Passer down the cannula and push it through the base of the labrum. Depress the black button and push it forward to release the suture into the joint. Pass the SwiftStitch through the mid substance of the labrum and retrieve the suture, and pull out all slack from the suture outside of the cannula. Pass the white end of the repair suture through the loop of the shuttle suture, and pull the non looped end of the shuttle suture until resistance is felt. Gently pull 3 to 4 light tugs to pass the repair suture back through the anchor sheath. Pull on the repair suture to get the initial tension outside of the cannula. Load the repair suture into the suture tensioner. Cutter for final tensioning and cutting. Insert subsequent anchors to complete the labral repair.

This animation demonstrates the steps for closing an interportal capsulotomy with the CapsuleClose Scorpion™ suture passer through a single portal. The steps for loading and unloading the device are outlined, as well as how to pass mattress stitches through the iliofemoral ligament for closure at the end of a hip arthroscopy.

CapsuleClose Scorpion™ Suture Passer

The capsule closed. Scorpion allows the surgeon to pass and retrieve suture while repairing the capsule following hip arthroscopy. Lota number two. Fiberwire suture into the distal jaw of the capsule. Closed Scorpion by pulling a looped end into the small slot until it is fully engaged. Introduce the capsule closed Scorpion through an 8.25mm TRIM-IT cannula. Grasp the capsule by squeezing the front trigger of the Scorpion. Advance the needle by squeezing the rear handle until a click is felt. Rotate the Scorpion to disengage the bottom jaw from the tissue and remove. To release the FiberWire suture from the needle. Squeeze the rear handle until the needle advances. In preparing for the second pass through the capsule, load the opposite end of the FiberWire suture into the small slot as done previously. As the CapsuleCut Scorpion is introduced back into the TRIM-IT cannula, pull the slack out of the previously passed FiberWire. This will prevent looping of the suture as the Scorpion advances through the cannula. Repeat previous steps by first squeezing the front trigger, followed by the rear handle to pass the FiberWire suture through the capsule. Remove the Scorpion from the cannula and release the FiberWire suture. Tie a sliding knot of surgeon's choice to close the capsule and continue with additional passes as necessary.

David Sedory, MD, (Savannah, GA) outlines a technique using the CapsuleClose Scorpion™ suture passer for passing traction sutures through the proximal and distal limbs of an interportal capsulotomy to suspend the capsule during arthroscopic hip procedures. Dr. Sedory demonstrates the increased visibility these traction sutures provide for performing an acetabuloplasty, labral repair, and cam osteochondroplasty procedure.

Capsular Retraction and Suspension Technique Featuring the CapsuleClose Scorpion™ Suture Passer

Hi there. My name is Dave. I'm an orthopedic surgeon in private practice in Savannah, Georgia, and I'm here to share with you the technique that I prefer for managing the capsule and hip arthroscopy. This is tentatively called the capsule suspension technique or capsule retraction technique. And we make use of the capsule closed Scorpion to traumatically tag the capsule on both sides of the hip to pull it up and away from the working space, while preserving the capsule for later repair. We have a left hip specimen here, and I have placed three portals. We've already made our inner portal capsulotomy. We've used the TRIM-IT, Cannulas and all three of the portals to give ourselves an easy in and out from the hip without traumatizing the soft tissue. Certainly this can be done with less cannulas if necessary or if desired. We have a standard anterolateral portal which was our entry point into the hip, a anterior portal or modified mid anterior portal depending on preference, and then a distal anterolateral portal, which is easier for anchor placement, as well as for suture management and the capsule closure sequence. And so, without further ado, we're going to get started working in the joint. And I'll kind of show you where we're at. So we've made an inner portal capsulotomy here. Our labrum is here anteriorly, looking around posteriorly at the hip, we can see the backside of the labrum and down the back of the hip. This is a young specimen who happens to have really good cartilage and soft tissues, which is certainly helpful to us. The majority of patients we can get by with the inner portal capsulotomy usually about three centimeters in size. And I'll show you here shortly how we preserve the capsule, which really facilitates later closure. Small technical note during the course of the procedure, after the acetabular work is done, it's really nice to pull the camera back outside the hip and remove some of the fatty tissue on the backside of the capsule. This really facilitates later closure of the capsule if you want to view from the outside of the hip while doing the closure, certainly you can close from inside the hip, but then you're going to be tying blind after suture passage. And so that's certainly user preference. So we're going to show you here quickly the capsule closed device. It's a very easy to use device is loadable at the distal aspect. Just snaps into place just like just like everybody's used to with the regular Scorpion. And then it's a self retrieving device, which is really beneficial because you can come in through one portal, retrieve through the same portal, and grasp the suture as you pass through the capsule, and so it grabs it every time. I prefer using FiberWire for the suspension technique. So when we made this capsulotomy, we used the CapsuleCut blade, which is a monobloc blade that has a very sturdy handle on it. This gives excellent leverage for making the capsulotomy from different angles. And so once we come in with the nitinol wire through our needle, we place a small either 4 or 5 millimeter metal cannula down, and then can use this to sort of make our cut between the two portals. If necessary, the camera can be switched to the anterior portal, which will then allow completion of the capsulotomy. And we'll start the tagging sequence using the capsule closed device in the anterior most aspect of the hip. So we're going to pass our our capsule closed down, get it in the axilla between the labrum and the capsule and then fire. And there should be an audible click. You can actually feel it click in your hands. And then as you release the trigger you'll see the suture pull forward. So that tells us we've captured. I'll rotate my hand about 90 degrees back towards me and partially close the jaws, which will allow us to slide back in the cannula without pulling our suture out. And then on the outside of the skin, it's as simple as just firing the needle, and we can release the suture. So now we're going to repeat this a second time with another FiberWire. And we're going to come straight back down the same cannula in the same path. And again kind of tuck up into the axilla here between the labrum and the capsule for our second pass. Come down, fire the sutures, turn our hand and pull back. And we've now released. So we've got now a hold on the capsule from the anterior portal. And so we're going to pass the switching stick down now. And for me the key to this suspensory technique is once we have the first two sutures passed, we're going to pull our cannula out gently. And then I'm going to take a Kelly or other hemostat type device. We're going to pull gentle traction on both pairs of Pairs of sutures, slide down with the hemostat onto the skin and then snap it there. Slide our cannula back into the hip, which will give us passage, and then we can again adjust our tension on the stitches by holding this down against the skin. Okay, so now we have tension on both sutures pulling the tag stitches up and away. And now we're going to switch our camera to the other portal. And we're going to repeat this more onto the back side of the hip from our other cannula. All right. So here we are coming in with the capsule closed from the anterolateral portal. The labrum is here. We're going to tuck right behind the labrum and get up into that capsular tissue in that recess between the labrum and the capsule. Close the jaws and fire. We're going to turn our jaws towards us and then slide gently back and then to release the suture, fire the back handle without the front lever and it releases. And so now we're going to pass one more FiberWire again coming working back towards the camera here. And so again on this one pair of suture or this one suture we already have placed, we'll pull a little tension so we don't get tangled as we go down. We'll pass easily down our cannula. And again we're going to walk back a little bit towards our camera. Get into the capsule between the labrum and the capsule. Fire the device. Suture has been retrieved. Turn our hands and pull back slowly and then release. So now we have two sutures thrown through the anterolateral portal, two sutures thrown from the anterior anteromedial portal. Our look at our traction sutures coming out the anterolateral portal. And if we switch our camera back, we can see our anterior sutures coming out that portal. We come along, up and along the edge of the acetabulum in a relatively quick fashion. We have accomplished a fairly wide exposure of the acetabulum, and this can be extended more posteriorly if desired. It can be extended down a little more anteriorly if desired, but I try to maintain as much of this medial cuff of capsule as I can. It starts to get thin. You also start getting in towards your iliopsoas tendon. And so most of the work, and probably 90% of the hips that you're going to do are going to be in this anterior superior quadrant, which in general this exposure is more than adequate for. So we have now taken the tension out of our sutures. And so here is sort of what your basic view would be if we had just let the capsule sort of free float without pulling any traction on that area, which is certainly fine. And you can get in and do the work that you need to do. However, as we pull up, you can see how easily that lifts up and away and the great clear view of the rim that we were able to obtain with just a passage of a few simple sutures at the beginning of the case, we now have the traction off. So the the hip is now reduced. The femoral head is in the acetabulum. We are now staring at the capsulotomy. And if I pull back a little bit, you can still see my suspensory sutures, which is pulling the capsule up and away from the hip. What we're going to do now is we're going to put a couple of tag stitches in this distal limb of capsule. I think it's really important just to take a couple of minutes once the traction is off, to clean off the fatty tissue on the backside of the capsule. Place a TigerWire suture using the capsule closed device and we'll come in upside down for this. So we're coming in through our dollar portal. I am hooked between the femoral head and the capsule, and we're going to fire our stitch. Okay. And so our stitch is passed. We're going to close the jaws some. And we're going to pull back out of our cannula and we're going to release. And so now we have one stitch placed and we're coming in. We're going to put one more stitch immediately adjacent to it. And so what we're doing right now is retrieving those previously placed stitches out of the cannula. We'll take the cannula and slide the cannula back in. Ideally in a similar plane. And then place again another Kelly or other hemostat device to hold those that capsule up and away from the femoral head. And so what you can see now that we have all of our traction stitches in, I can control the capsule using the stitches and I can control the tension against the skin using the hemostat. This allows great visualization of the head neck junction. We can rotate posteriorly and see this, and it allows us to lift this capsule up and away from the femoral head neck junction. During the camera section here we have our our bur in the hip, and we're kind of finishing up the anterior portion of the camera section with the hip a little bit more flexion. So one of the benefits of the suspension technique is that you kind of have your choice on which sutures you want to use to help your closure. Most of the time, I think the more challenging of the passes is on the acetabular side. And so that tissue tends to get a little thinner quicker. So multiple passes through that tissue can be a little bit challenging I think increases your risk of the tissue or the suture cutting out of the tissue. You know, with this view the benefit is that we can see our two posterior passes and then we can see our anterior passes up front. So what we'll be able to do here hopefully, is to reach in through our Dalla portal and then retrieve those pairs of sutures in order to repass those through the capsule, which then helps with our closure. And so what I'm going to do is I'm going to remove our two sutures here that were placed into the distal limb of the capsule so we don't get tangled up, and we're going to come back in with a CrabClaw, and we're going to retrieve some of our anterior sutures to try and help with our anterior closure. So you can see, here's our suture for that came out through the undersurface of the capsule there. And our more anterior suture pair is right here. So we're going to simply retrieve these two out the distal portal. And so what we'll do is we're going to look at these two tissue pairs and figure out which one is the one coming underneath the downside or the bottom side of the capsule, which is the one that we're going to want to pass through this distal leaflet. So if I pull on this you can see the one that I'm pulling is the outer leaflet. And so that is not the one that we're going to want to load into our device. For me what I've found is, is very helpful is to have your assistant as we come down this cannula to pull on the free strand. This prevents tangling. And so we're going to kind of walk ourselves down the limb that we've pulled tension on behind us. We have no redundant suture inside the joint to get tangled, and we just have our suture in the capsule closed device. So we should be able to come down nicely right here onto the distal limb of the capsule. Fire, pass the suture, and then rotate our hand in a manner that allows for retrieval of our suture pair. And now we have our first pass okay. And so what we'll do is just close this with a standard arthroscopic sliding knot. And then we're going to work back towards our camera as we close and grab the sequential pairs. Since we have such a great view on the outside of the capsule. So what we can see is that now that we have completed our closure, I'm just viewing this through the Dalla portal so that we can actually see that Capsulotomy. We now have a nice complete closure of our capsule. I usually place a minimum of three sutures in the inner portal cut, but we certainly have a nice, nearly watertight closure of our capsule, which should heal up very nicely and recreate the anatomy without removal of tissue.

Labral Repair/Reconstruction

Labral Fixation

Suture Passing