Name: Techniques and Treatment Outcomes in Knotless Hip Labral Repair
Uploaded: 2016-07-25T00:00:00Z
Channel: Arthrex

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VPT1-00668-EN | A | Techniques and Treatment Outcomes in Knotless Hip Labral Repair

David King

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Techniques and Treatment Outcomes in Knotless Hip Labral Repair

I'm going to be talking about techniques and treatment outcomes in knotless labor repair. So the labrum has a function. It increases the acetabular surface area and volume. It controls fluid flow. It provides a suction seal which is important for stability. It protects the cartilage from compression and it reduces contact stresses on the articular cartilage. The labrum has a very unique anatomy in the hip. There is this spike of bone that we've seen this this different image in this anatomy slide several times. There is a part of the labrum that contacts the capsule. And then there's where you get a lot of the blood supply to the labrum. And then there's a part of the labrum that goes down to contact the articular cartilage to create this transition zone. There are many ways to refix or to repair the labrum. There's a simple and looped SwiftStitch sutures. There's base fixation. And there are some other more anatomic atomic options using the Knotless SutureTak that will go through as well. You need to know how to do every one of these because certain situations are going to require different techniques. What are the benefits of a simple or a looped stitch? In this case, this is a image showing a doubled over suture that has been looped on itself to really grab the circumferential fibers. So when you have a pincer lesion and you have that highly degenerative labrum, where it's creating that fraying of the labrum itself, you want to wrap those sutures circumferentially to make sure that you have a stable repair. What's the downside is that you can Evert the labrum. If the purpose of the labrum is to contact the femoral head. And then we needed to stay there. So if you're if you're doing a refixation or a labor repair and you're significantly everting the labrum, then I question whether we're doing our job. What's the difficulty using these techniques? We'll go through some of that stuff as we go on. So here is an option of where I would use that technique. So this patient has an OS and they have some intra labral degeneration. So in this case they had a combined mix. So they had a pincer lesion. They had this with this OS. And then they had a Cam deformity causing this transitional zone delamination. In this particular case we removed some of the tissue around the OS and then we start to remove it. I like to use a burr from the capsular side. I start to burr this down in a gross fashion, staying away from the labrum, making sure that we are not destroying any of the quality labral tissue. When we've created more of a thin component, I'll come in with a biter or whatever device I have, that pituitary rongeur or something that that nature, again, we are we are trying to take out just the unstable portion of this and leave the remaining fibers of the labrum to repair and to refix. We're going to do our pincer resection, we're going to prepare our rim. And then in this case we did a looped fixation. And we had enough labrum in this situation to do a loop repair. We did not invert it. And then we are able to recreate a suction seal. As you see right here. So that's your classic simple loop. It's the easiest one. It's probably the the one everybody should start off with. If they're not doing a lot of labor repair. But then we evolve. So the concepts of base fixation has been around for a while. Doctor doom wrote it up in arthroscopy I believe it was 2013 with some nice diagrams to give you a better, better idea, but there's also big variations on how you do this. What's the benefit to a base fixation? More AnaToemic. You get improved labral contacts so it can do its job. It's more demanding. You do violate the labrum in some degree, which can affect stability. So in this situation, we've drilled our pilot hole. We're going to do this Knotless. This is an older video where I'm using a BirdBeak. Now we use the Scorpion and we're also using SutureLasso. I believe there's also some micro lassos coming out. So you have even less of a violation. But on this more hypertrophic larger labrum you can come through with a simple BirdBeak. Then I come, I come usually where there's a little blush or change in the tissue, and I will come right at that junction and pierce through again. You can do this with the labral Scorpion, which works quite nicely for these larger labrums. You can do it with a lasso. There's varying techniques. We're going to grasp that. Slide it back up through. Then I'm using a short PushLock Biocomposite PushLock in this case. The other benefit to this base fixation is you can move your anchor a little further away from the rim than you'd like to to do, and that what's the benefit of that? We don't get those articular cartilage penetrations that we have all experienced. Or hopefully we're looking at the articular cars and we just start to see a little wave in it and we stop ourselves. But when you're doing this base fixation, you can definitely scoot a millimeter or so further away from the articular surface to avoid performing a iatrogenic penetration of the articular cartilage. Here's just a second anchor going in. I have actually converted to using an OA FiberWire when I'm using these PushLock because I there's less friction in binding, so I get less eversion, especially if I'm doing a cinch stitch. There's our anchor going in. And here's a nice view of the undersurface. You've left that leading edge. You've still got a nice controlled repair, minimal suture on the articular surface. And now we'll go to the next topic, which is a more anatomic fixation. So the new knotless SutureTak. What are the benefits of it. Even more anatomic options. It was peek. The one I've used was peek. But I understand that there's a biocomposite that just came out. Hopefully they can confirm but I'm pretty sure of that. You get improved label contact. You get much greater control of being able to tension it. And unlike some other devices from other companies that have a situation where you can tension, after you've placed your anchor, you're able to remove the device or the handle. So you can actually visualize as you're doing this, which is different than some of them, you can place this blind. So if you've if you've done a repair and then you realize you got to go back far anterior or to that 9 or 3:00 position Depending on what hip you're doing, this can be a great anchor for that too. It is more demanding and there are some there are some subtleties with it. This is just from the Arthrex literature. This is available online. You can watch videos of this Truefitt cannula. I've switched to this at this point. It's awesome if you guys haven't used this. The way it grips at the skin, the way you can trim it down, it's it's a game changer compared to the rigid ones. So in this situation you can get very close to the rim here. You're going to impact this. Here's that. Scorpion coming through. And then you're going to shuttle your suture through. And when you're finished you're going to have the nitinol guidewire coming from the capsular side outside of the joint. You're going to be passing it through the night all guidewire. And now you can after it's down, you can tension it and it and you can. It's a one way catch so you don't. That's it. It's loose. Now you're going to slowly, bit by bit with the inserter out you can slowly tension it down. It's got a lot of benefits and I know I don't know if Ben's still here, but I think he's doing this almost exclusively. Here's just coming from a different angle angle. And then you get this. You can also pass this in a base stitch fashion. You can use it in any technique you want. This was a more thin labrum. So I decided to wrap it around. Data. Not a lot of data looped versus pierced was looked at through Philippon in 2015 didn't show a difference. Doctor doom showed that the base stitch works more recently, however, in 2016, the biomechanical article came out which showed that vertical mattress configurations versus horizontal were superior, and the smaller the device that penetrates the better. So that's why moving away from a BirdBeak like I showed in here, moving more towards the meniscus. I mean, the labral Scorpion moving towards micro lassos, those kind of things can be beneficial. So there are different suture options. There's FiberWire, there's LabralTape, there's SutureTape, there's all sorts of different materials. You can use different angled lassos, just like we're using in the shoulder. Play around with all these things. Have your have your reps, bring them in and see what you like the most. Pushlock anchors. We got all different types. We've got short, we got peak, we got Biocomposite and then play around with the suture Knotless SutureTak get used to it. It's good to have in your arsenal. Pearls stabilize the labrum. If it's a big labrum you've got options. You can do base stitch if it's small and if it's beat up in doubt, wrap it. That's my opinion. Restore the normal anatomy. Anything you need to do to to to do that. Occasionally I'll try to put a cinch suture around on a smaller labrum, and I will start to feel like I'm everting the labrum. I'm going to pull it away, it away. And you're not going to get your suction, steel. Be willing, if you have to, to burn an anchor in that situation. Change your technique and do something different. If you don't have the right angle and you're going to bubble the cartilage like I showed, back off, go to a distal mid anterior portal so that you get to different angle. Be willing to challenge yourself and use some different techniques. You're going to make some mistakes. You're going to you're going to pop through the cartilage. It's going to happen if it hasn't already, to you just try to do everything you can to limit those mistakes and to have a bunch of options to get you out of a jam. My favorite thing in fellowship with Peter Millett and shoulder surgery was when we'd fix something and he would pull a towel off the tray, and it had all I was allowed to use to fix something. And it would be a nitinol guidewire and a suture and and a and a and a and a 18 gauge spinal needle. And it was in one anchor and that was. That's all you had. It's fun to challenge yourself doing the same thing over and over again. We can tend to get a little complacent. So I challenge you.

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