Name: Knotless Labral Repair With PushLock® Anchors
Uploaded: 2019-04-29T00:00:00Z
Channel: Arthrex
Description: Mark S. Muller, MD, (Dallas, TX) presents a technique for acetabular labral repair using short 2.9 mm PushLock ® anchors for a knotless construct that anatomically restores the function of the labrum and the suction seal of the hip joint. Dr. Muller outlines the importance of using a low-profile construct and the significance of labral tensioning in the hip.

<p>Mark S. Muller, MD, (Dallas, TX) presents a technique for acetabular labral repair using short 2.9 mm PushLock<sup>®</sup> anchors for a knotless construct that anatomically restores the function of the labrum and the suction seal of the hip joint. Dr. Muller outlines the importance of using a low-profile construct and the significance of labral tensioning in the hip.</p>

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VID1-000117-en-US | C | Knotless Labral Repair With PushLock® Anchors

Mark S. Muller

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Knotless Labral Repair With PushLock® Anchors

Well, thanks. I'm, I'm Mark Mueller from Dallas and I'm going to go over my labor repair technique, which is a knotless technique. And I'll go over sort of the rationale and then some some technical pearls of how I do it. So about me, I started in 2007 Scorpion hips and did my fellowship in New York and started really with just all labeled agreement, selective labeled agreement. I probably scrubbed in on or watched Brian Kelly do 100 to 150 hip scopes in my fellowship, and he didn't put a single anchor in the hip in my fellowship. So obviously practice has changed significantly in the last 11 years, probably within the first year out of in in my practice, I was doing, you know, 90% of the hips or 95% of the hips. I was scoping, I was doing labor repairs, I was doing and tying knots. And I have transitioned away from that now. And I do pretty much knotless repairs or reconstructions for, for almost all of my hips. My primary concerns are these. With tying knots. I think that that knots do migrate. That certainly published in the literature and the shoulder. And so they can cause iatrogenic chondral damage. We also see intra-articular adhesions from the knot stacks. And I'll show you some examples of that. And then I think in the hip it's unique. I mean we have we have some very close approximation of the iliopsoas and the reflected head of the rectus to the anterior superior rim. And I think the knot stacks can be a problem there. And then the last is I think that you get eversion of the labrum tying knots often that you can avoid if you technically do knotless fixation the correct way. So certainly adhesions are well described in the literature. And in Mark Philippon's initial revision. Hip arthroscopy group 37 cases, 62% of them. He felt like had symptomatic intra-articular adhesions. I'll give you a few examples of this. Here's a Division one rower, 20 years old year out from a hip scope, anterior hip and Pain and popping positive impingement signs tight hip flexor. And you can see just a direct capsular adhesion band going directly to that knot stack. This is a different example. Here's a 28 year old volleyball player and coach nine months out from a hip scope, persistent anterior hip pain and popping, and you can see a knot stack there just encased in scar with, again, an adhesive band going directly to that knot stack. That's just a revision of it. And interestingly, you can see the iliopsoas that I exposed there just beneath that suture knot stack. And so I'll show one final case that is similar. 30 year old six months out from a hip scope has a popping now iliopsoas that that she did not have preoperatively prior to her first surgery. So here's a left hip and I'm looking down the rim, and you can see I'm kind of exposing some adhesions around that suture knot stack. And you can that's the psoas right there. And so this is a left hip in traction obviously and an And an extension. But you can imagine in hip flexion you can see how bruised that labrum is, and you can see the close approximation that it has to that lowest suture, not stack. And so you can imagine in hip flexion that that psoas would impinge along that suture not stack. So I'll go on that is treatment of that. I think that the eversion issue is an issue that I, that I saw a lot from, from people that were tying knots and doing these cases in, in my area. And I think the problem is this, that if you look at the left, if you're tying knots and you have a post limb and a throw limb and really the only suture limb, if you're doing a label based refixation that's going through the labrum is your throw limb. And so as you tie that down, you're really pulling both portions of that labrum back to the post. Whereas if you correctly do a knotless fixation, you have a capsule, what I call capsular cited limb and an articular sided limb. And if you can differentially you can differentially tension those if you know how to do it and technically do it right. And you can invert or invert the labrum depending on what your tension is, on which limb. And even if you do the old fashioned luggage tag technique and you pass it correctly, the two sutures, if you have them coming out the articular side, if you're doing it into a knotless fixation, the only thing that's really going into the anchor are the limbs that are coming out the articular side, which will have a tendency to keep the labrum from everting as much. So this is my gold standard repair. Again, only knotless fixation in my hands allows me to do this where I can Evert and then invert and then invert and basically put the labrum wherever I want. And so in my hands, I can recreate the anatomy and the suction seal better using knotless fixation. Here's Ben's article from a few years ago where he talked about the six goals of labral repair. And I think the first four of those goals are all about restoring the labral anatomy. The fifth goal is to get the get the seal right, and then you'll get the labrum to function correctly and then do it in a knotless way, if you can, to avoid iatrogenic cartilage injury. I passed my sutures in a number of different ways. I still do go circumferentially in some cases depending on labral size as well as the quality of the tissue, and then do labral based fixation as well. So here's my technique. Pre-drill my holes. I'll pass a suture through or around the labrum with a with a small diameter suture penetrating device. I'm not operating through a cannula, so I'll pass a claw or a suture knot pusher or something over that. And then put a sled down for the anchor to go in. And then what I'll do if you can hit that video as well. I will again tension the two limbs independently. And so I know that's my articular side. I'm going to invert with my with my capsular sided limb. And then I seat the anchor, and I'm preferentially putting more tension on the articular sided limb to resist the eversion tendency of the insertion of this anchor. And so you'll see, you can you can recreate a normal labral seal as long as you're managing your sutures properly. And so off traction. These tend to look like this. And you can get a nice labral seal whether you do it. Circumferentially as in this case, or you do it with a label based fixation, as long as you're paying attention to the way that you're holding your sutures and tensioning your sutures, and you can recreate normal anatomy and then recreate normal labral seals. I do it in a similar fashion with label reconstruction. So here's a segmental labral defect. And again here's pre-drilling the holes graft passage labral base fixation and then off traction. You can see a normal, you know, labral seal using knotless fixation. So for me the advantages are I do not get soft tissue impingement from the psoas or reflected head of the rectus. Avoid adhesions, avoid damage. And then I could better recreate the anatomy and the function of the labrum. Here's the we now have midterm five years. It's great that we can see five year data now from sows. So here's the visual analogs. You can see they kind of at 3 to 6 months. It kind of plateaus. But we see improvement between two years and five years. In the Vas, as well as the modified Harris hip scores, which have that 20 point improvement, which kind of plateaus around 3 to 6 months. But then you see improvement, you know, beyond in that 2 to 5 year range. I use the short two nine typically. I think there's a number of options from Arthrex, which is great. I think the two nines pull out strength. Pull out strength isn't everything, but it certainly is indicative compared to the peers compared to other implants on the market. The the short two nine certainly has adequate fixation. Do I tie knots? I still do in my practice, but it's generally only in areas where I don't feel like I have adequate bone for A29 anchor. And so I'm usually if I'm doing that using all suture based anchors. So again, in my practice, I've transitioned from knot tying to knotless. And I think it's allowed me to do all of these things. Thanks.

Knotless Labral Repair With PushLock® Anchors

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