John Cristoforetti, I'm an orthopedic surgeon and an ANNA member, and I've been involved with OLC courses for the last 12 years. Congratulations on selecting one of the top educational experiences that you can have in order to improve your technique. I want to thank the course hosts and organizers for inviting me to share this short technique on knotless label repair, utilizing our standard techniques for a knotless label repair. These are my disclosures. This reference here in the slide indicates the reasons why a surgeon might reasonably consider eliminating knot tying from their acetabular label refixation or at minimum learning a way to incorporate knotless refixation constructs. Our approach to knotless refixation begins the same way as all of our standard cases begin with the patient positioned carefully in the supine hip arthroscopy position. We indicate patients who have failed extensive conservative management, typically involving therapy, activity modification, and intra-articular injections to confirm the source of the problem in the hip joint. Details associated with positioning can be found in the Arthroscopy Association Master Techniques book and in recent publications by Maydown et al., documenting the appropriate addition of Trendelenburg and the ability to perform central compartment and peripheral compartment arthroscopy without the perineal post. The case demonstrated here is a postless case on a standard OR table. We utilize anterolateral mid-anterior portals as described by Robertson and Kelly with accessory distal anterolateral accessory portal for accurate targeting of knotless anchors. The table is managed with a periportal capsulotomy in this non-impinged case as published by McGovern et al. The technical concepts associated with knotless repair are important to consider. Preparation of the acetabular rim is something that is done in variable manners. You must balance adequate exposure and preparation of the bone for healing against the iatrogenic destruction of normal tissue that may result in excessive scar or excessive need to refixate the labrum. Suture passage through the labrum is also an area of consideration. The method of penetration of the tissue for suturing is simple, which is an around and around suture, or a labral base pattern as described by Dohm et al., where the base tissue of the labrum most adjacent to the acetabulum is captured, leaving the edge free. An additional technical consideration is the pilot hole drilling in the acetabular rim. When anchors are placed in any position, whether knotted or knotless, a typical construct involves a guide followed by a drill, leaving a blind end hole. The location of this hole relative to the articular acetabulum is very important, as well as the relation of this hole to the deep structures of the inner table of the pelvis, whereas case reports of penetration and so as irritation have been reported. The allocation of the anchors along the repair area documents the number of anchors for the clock face convention of 12 o'clock to 3 o'clock anterior, 12 o'clock to 9 o'clock posterior acetabular arcs. We have had prior publications within the MASH study group documenting that approximately three hours of tear justifies at least two anchors. There is no existing evidence that is more defining than that. One of the technical allocation considerations is refinding or relocating visually the drill hole when you've placed a socket that a knotless anchor may or may not be capable of immediately filling. Some modern anchor constructs in the knotless design require the guide to be placed, the drill hole to be placed, the guide to then be removed, and then separately readdressed the hole with the knot over the suture construct. This makes for a more difficult placement, particularly far anteriorly or far posteriorly or with more limited soft tissue exposures. Certain knotless constructs do allow the drill to go through the guide, followed by immediate placement of the anchor into the drill socket. Finally, selecting the appropriate tension of suture within the labrum for the ultimate repair is something that is much more difficult with a knotless construct depending upon the system used. So some pearls. When we're doing knotless or when we're tying knots for labor repair, the tension of the suture within the labrum must be carefully assessed to avoid eversion of the labrum or frank pull-away of the labrum from the head. This would result in loss of the suction seal of the hip joint and may well make an outcome inferior to non-surgical care or labrum sparing limited debridement. This, of course, is my personal opinion. Knotless anchors require excellent understanding of the whole path to drilling from the skin all the way to the bone of the acetabulum as well as placement of the anchor. Knotless techniques are unforgiving of anchor changes, angle changes, and other types of adjustments that are required based upon the small size of the anchor and often the need to reacquire the drill angle for placement of the anchor. They are also unforgiving for larger segments of labor repair if they're not a variably tensionable knotless construct. Knotless anchors with simple loop sutures and a large labrum can most easily create non-anatomic repairs because the tension set within a knotless construct, again, can compromise the suction seal. Finally, a pearl is to assess your repairs with the hip reduced in order to allow for the understanding of the suction seal, and you should never hesitate to remove that stitch, cutting it away, and restarting if your suture repair has made the overall labrum worse for wear. This video is going to take us through a knotless arthroscopic labor repair. This is a right hip viewed from the interlateral portal. The probe is entered from the mid-interior portal demonstrating a hypertrophic labrum with a tear at the base chondrolabral juncture tissue with a base of fibrocartilage. The synovitis reaction is obvious. The mid-interior portal is used to perform synovectomy through a very small periportal capsulotomy. The outside view here demonstrating the rim preparation of the labrum with a ball rasp demonstrating the vigorous nature that the ball rasp can mechanically debride in a non-acetabuloplasty setting. Another opportunity does exist for rim preparation after the ball rasp has been removed, and this is first assessed utilizing the radiofrequency probe. We can look above the acetabular labrum, noting the intact capsule. We see that the half pipe cannula is what we use through the mid-interior portal throughout knotless repair to allow maximum instrument mobility inside a small capsulotomy. The next video, once we can see the mobility from the outside view, the next video demonstrates for us the standard tangential view rim prep, note the 5.0 millimeter burr and less than one millimeter of decortication for preparation in this case, and the labrum itself is peeled down away from the rim of the acetabulum as part of the natural tear pattern. The final method of preparation that we'll use is utilizing a flat liberator device, and we can lift that liberator away from the articular detachment, and you can see utilizing what we call the bird's eye view and the live outside view shows that we move not only the camera, but also we move the oblique with our camera hand, giving us visualization both of the articular surface as well as the acetabular labral rim. This preparation completes the preparation phase. Next we assess the angle in demonstrating the distal and trilateral accessory portal access. Once the distal and trilateral accessory portal is established, we are capable of moving on to this variation of knotless anchor is an anchor that is capable of being placed through the drill guide immediately following the drilling socket. The outside view demonstrates the assistant holding the camera steady while the operative surgeon drills the pilot drill guide. We view the articular surface intra-articulately at all times to avoid penetration. We use a nitinol wire to tap and sound the bottom of the hole to be certain we've not penetrated the deep table of the pelvis, and then the all suture knotless anchor construct is placed inside the socket. Once the anchor is placed inside the socket, the tension is checked to ensure that it is securely seated within the drilled socket, and then the sutures are removed from the drill guide. You can see in the arthroscopic view that the anchor has been placed, and there is, in this particular anchor construct, a shuttling construct that brings the stay suture through the anchor mechanism after passing around the labrum. We use suture management across the half-pipe cannula, tagging both the passage sutures for the anchoring of the suture within the anchor construct, and we also separately like to clear any bridges or twists utilizing a ring grasper, visualized both outside and in. We want a clear path for knotless refixation. We want no heavy angular press of your instruments for knotless refixation, and as we can see that we've left inherent stability of the chondrolabral juncture in our rim prep, we are allowing ourselves the maximal opportunity in order to allow for refixation of the labrum without having created iatrogenic excessive labral instability. In the next step, we use a small integrated passer, and this passer will be penetrating through the base of the labral tissue with the knotless anchor stay suture. We'll visualize in the arthroscopic image the grasping of the stay suture. The white striped sutures are sutures that are used to pass the suture that will stay with the repair through the deep construct in the bony tunnel. First we check the tension on the blue stay suture by past pointing into the joint. Next we use that extra length of suture to pass on the labral base side of the detachment. The next step is to use the ring rasper to more securely pull our first passage through to avoid any excessive tension on the knotless repair construct, and this is an important step utilizing the integrated passing devices. These can cut the sutures or make for a difficult passage on the second pass. Now a simple knotless repair suture would be taken around and around by simply pulling this suture all the way around the labrum, but in this case, since the labrum was a very large labrum, the decision was made to go for a knotless labral base refixation pattern, and the way that's going to be achieved is by separately re-penetrating from the capsular side of the labrum through to the articular side of the labrum with the small integrated passing device, as shown both in the outside and inside view here. While maintaining tension on the suture construct feeding sutures, the integrated passer can be brought through the labral base tissue, through the mid-aspect of the labrum itself, and then that suture can be captured and re-delivered yet again through the labrum, so now it's gone from its bony interface through the chondrolabral base tissue, and then back out the mid-sub of the labrum, again we simply make the pass with that instrument, and then we use the ring grasper to re-grab the loop created by our integrated passer, and then we pull that loop out using the ring grasper, which is designed in order to allow smooth engagement of the tip of the instrument with the suture itself, and this again prevents suture tearing or pull-out. What's most particularly important is maintaining good tension and good understanding of any twists or knots that can form. As you can see here, we've left a small twist inside the suture construct. This is simply re-threaded out with the ring grasper, allowing now for a clear passage of the knotless suture anchor construct down through the actual passing suture, which will allow securing of the labrum to the rim. On the external view, we can see us removing the last final twists of the knotless construct. Once those are removed with a ring grasper, shown deep, and then pulled out to the superficial view, we can then pass the tail of the stay suture through the knotless shuttle suture construct. This is checked to be certain that it moves smoothly. Our assistant's camera position is checked, and now we have a steady working portal that we're capable of passing through. We make one final pass directly down the suture using the ring grasper and removing any final twists associated with any obstruction for that knotless repair. This is something that's very important to avoid binding of any of the commercially available knotless constructs is making certain that there's a clear path for your sutures all the way down. Certainly, a circumferential cannula or a closed cannula system can be used. The half-pipe cannula is used in this case in order to facilitate as much possible room deep within the joint given the small capsular window that was created in the PERI-PORTAL technique. Next, we'll see the shuttling of the suture down through the half-pipe cannula with tension maintained in the knotless construct. This is a standard technique for the manufacturer to pull the suture through. We can see in the inside view the suture that is the stay suture that is passed through the labrum and is now routing back into the suture anchor mechanism on the rim of the acetabulum. Because it is a tensionable construct, we're capable of separately tensioning this rather than a standard all-at-one knotless construct which does not offer the same tensioning options. We will use a hemostat to protect the fingers as we tension. I'll use an arthroscopic knot pusher to control and hold our pull in line to be certain we don't explant the anchor from the rim. We'll watch as the final repair step is completed, noting that the labral base suture does not circulage the entire labrum, but rather, given the hypertrophic nature of this labrum, we're able to tension that labral tear back to the rim, really re-securing that labral base detachment without everting the labral tissue. And then a standard arthroscopic suture scissor is used to transect the labral repair. This is the first of two anchors used in this particular repair construct. We can see that this is preserved, and the entirety of the labral tissue, there has not been a antigenic compromise in the femoral head. We can see that the labrum, with slight probing, was appropriate for a second anchor in the position more laterally, which would follow the similar steps. And we can see the final repair construct. So that is the simple completion of knotless S-tabular labral repair and refixation utilizing a knotless anchor construct. Thank you for your time and attention.

Dr. John Cristoforetti

orthopedic surgeon

ANNA member

knotless labral repair

acetabular labral repair