Abstract
Arthroscopic surgery, including implants and advanced techniques, continues to advance in the field of orthopaedics. The evolution of suture anchors has undergone design changes, passing from first-generation metal anchors, biodegradable materials, different plastic polymers, to all-suture constructs. Knotless technology also has been found to be a more reproducible method and have comparable outcomes with those found using knotted anchors. This Technical Note describes the advantages and different ways this tensionable anchor can be used in arthroscopic procedures. This implant and its understanding will be useful in the sports medicine area by simplifying procedures and making them more reproducible. The aim of the present Technical Note is to detail the simplicity and versatility of the anchor and discuss different scenarios in which this technology can be used to address common hip pathologies.
Technique Video
Arthroscopic surgery has become one of the predominant areas in sports medicine due to its minimally invasive nature and less morbidity with efficient results compared with open procedures. With that being said, there is a great interest in the improvement and development of new arthroscopic implants and techniques. In order to maximize their function, anchor design has undergone many advances in terms of both form and material properties since its initial manufacture in 1985 by Goble et al.,1 which consisted of bonding of polyester suture to a metallic headless hex screw, introducing metal anchors. Following this, different materials have been used in anchor designing, such as polyacetal, polyether ether ketone (PEEK), and most recently, all-suture anchors, in order to improve and avoid the complications of the previous generation.2 Arthroscopic knots became an essential part of the success rate of many arthroscopic techniques using anchors as part of the procedure.3,4 That success has always been in close relationship with the strength, accuracy, and reproducibility of the knots being tied, which require a surgeon’s learning curve due to the level of complexity. New anchors with tensionable, knotless technology not only allow surgeons to perform faster and more reproducible procedures but also allow them to provide unique tensioning options that can be used in many different techniques during hip preservation procedures.
Knotless technology has been widely adopted during arthroscopic procedures and has several advantages with similar biomechanical properties to knotted ones.5 Knotless anchors avoid pitfalls found in traditional knot-tying, such as soft-tissue- and cartilage-abrasive knots, possible adhesions, knot failure due to their technical difficulty, and knot inconsistency.6,7 In addition, knotless anchors can help reduce operating time. Knotless anchors, since their invention, have always been manufactured with a tensionable inserter-in design, which requires the tension to be applied before deploying the device. The most novel implementation in knotless anchors is an inserter-out design with self-locking technology. The first anchor with this feature was the Knotless SutureTak (Arthrex, Naples, FL), which consisted of a PEEK anchor body with sutures. The implementation of a self-locking mechanism on this design makes soft tissue compressed and rolled over the anchor, which gives surgeons the option of using different stitch configurations. At the same time, the anchor’s adjustable tensioning technology allows precise structural positioning and anatomical restoration. The most recent version is the Knotless FiberTak anchor (Arthrex), which is a soft all-suture anchor, allowing us to evade previous design complications8 without compromising its biomechanical properties,9,10 and it is also equipped with different guide options such as straight, curved, flexible, and different lengths. As a result of having different guide options, the anchor is able to be placed correctly and simply in anatomic areas where other anchors will not reach so easily.
This study was performed at the American Hip Institute Research Foundation in accordance with the ethical standards in the 1964 Declaration of Helsinki. This study was carried out in accordance with relevant regulations of the US Health Insurance Portability and Accountability Act (HIPAA). Details that might disclose the identity of the subjects under study have been omitted. This study was approved by the institutional review board (IRB ID: 5276).
Shuttle Mechanism
The Knotless FiberTak is equipped with a shuttling suture mechanism, which allows the repair suture to be passed through its locking mechanism. This unique feature has become a game changer. Once the anchor is inserted and secured in the cortical bone, there will be 3 suture ends: the repair suture (blue), the flat SutureTape (Arthrex) end, and the looped end of the shuttle suture (both black/white). The repair suture is loaded through the looped end of the shuttling suture and folded such that only the thinner aspects of repair suture are being pulled through the locking mechanism. Next, the SutureTape shuttle is pulled through the splice locking mechanism and is then continually tugged to give the desired tension to the construct.
Versatility and Application to Arthroscopic Surgery
The versatility of the anchor allows surgeons to use a variety of configurations to achieve the different desired results based on the procedure and anatomical area. We will now name and briefly discuss each of these anchors in this specific circumstance. Table 1 and Video 1 list and depict the techniques performed with knotless tensionable anchors.
Table 1.
Summary of Common Procedures Depicting the Versatility of Knotless Tensionable Anchors
| Procedure |
|---|
|
|
|
Hip/Shoulder Labral Treatment
The possibility of being able to choose the direction that our labral repair will undergo provides us with an accessible decision-making tool depending on the quality and characteristics in which the labrum is found.
Bone/Labral Junction: Eversion, Inversion
Eversion
Once the Knotless 1.8 Hip FiberTak Suture Anchor with #2 Suture, VE1 is securely placed on the acetabular rim, above the identified labral tear between it and the joint capsule, the repair suture is passed circumferentially through the chondrolabral junction. Following passage of the repair suture through the looped end of shuttle suture, the nonlooped end is tensioned, creating an eversion-type labral repair construct. Figure 1 depicts this construct.
Fig 1.
Images of a right arthroscopic hip labral repair with visualization from the anterolateral (AL) portal. (A) FiberTak anchor guide (G) is shown to securely place the anchor on the acetabular rim (A) above the labrum (L). (B) The repair suture (RS) is passed through the chondrolabral junction with suture-passing device (P) and then retrieved intra-articularly. (C) The repair suture is passed into the knotless mechanism through the shuttle suture and around the labral tissue. (D) Tension is applied to create an eversion-type construct. The inverted construct is shown (red arrow) next to the everted construct (green arrow).
Inversion
Again, with the Knotless Hip FiberTak Suture Anchor with #2 Suture, VE1 securely in place on the acetabular rim above the identified labral tear, between it and the joint capsule, the loop end of the shuttle suture is first passed circumferentially through the chondrolabral junction. Following this, the anchor’s repair suture is then fed through the loop and shuttled into the knotless mechanism, thereby creating an inversion-type labral repair construct. Figure 2 depicts this step.
Fig 2.
Images of a right arthroscopic hip labral repair with visualization from the anterolateral (AL) portal. (A) Knotless anchor (KA) is securely placed on the acetabular rim above the torn labrum (L). (B) The loop end of the shuttle suture (SS) is passed through the chondrolabral junction with a suture-passing device, cautiously to avoid damaging the femoral head (FH). (C) The repair suture (RS) is fed and shuttled into the knotless mechanism through the shuttle suture from inside to outside. (D) Tension is applied to create an inversion-type construct (red arrow), cutting the remaining repair suture with a cutting device (C).
Chondrolabral Junction: Eversion, Inversion
Eversion
Having a Knotless 1.8 Hip FiberTak Soft Anchor securely in place on the chondrolabral junction underneath the identified labral tear, the loop end of the shuttle suture is passed through the defect circumferentially. Following this, the anchor’s repair suture is fed through the loop and shuttled into the knotless mechanism creating an eversion-type labral repair construct.
Inversion
Once the Knotless 1.8 Hip FiberTak Soft Anchor is securely placed on the chondrolabral junction above the identified labral tear, the repair suture is passed circumferentially through the defect toward the capsule−labral junction. After this, passage of the repair suture through the shuttling mechanism, creating an inversion-type repair construct. Figure 3 depicts this in more detail.
Fig 3.
Images of a right arthroscopic hip labral repair with visualization from the anterolateral (AL) portal. A) (A) FiberTak anchor guide (G) is shown to securely place the anchor on the junction between the labrum (L) and the acetabular cartilage (C). (B) The repair suture (RS) is passed through the labral defect with a suture-passing device (P). (C) The repair suture is passed into the knotless mechanism through the shuttle suture (SS). (D) Tension is applied to create an inversion-type construct (red arrow). (FH, femoral head.)
Tendon Repair (Tendon Compression Bridge)
The suture staple technique is indicated in the setting of a partial-thickness tendon tear. This technique eliminates the need to split the tendon and replaces bone decortication with micropuncture of tendon’s footprint. Following the steps in the suture staple technique,11 the tendon’s insertion area is identified and examined with the use of a probe to identify any undersurface delamination. After the site's preparation, the surgeon inserts adjacent. Knotless 2.6 FiberTak Anchor with an interlocking configuration. The tendon compression bridge technique works with the anchor by shuttling repair suture from anchor A through loop suture of anchor B. Anchor B’s repair suture can be shuttled via loop suture of anchor A or an alternate anchor C. this process can be repeated as many times as desired with adjacent anchors creating either a staple (A-B, B-A), or a box (A-B, B-C, C-D, D-A) configuration. Figure 4 depicts the technique.
Fig 4.
Illustration of the technique for knotless suture staple endoscopic repair of abductor tendon tears. (A) Partial-thickness tear is located endoscopically. (B) Four knotless FiberTaks are then placed through the tendon and into trochanteric bone under fluoroscopic guidance. Two in the anterior leaflet and 2 in the posterior leaflet as demonstrated (C). Shuttling begins with the FiberWire from the posterodistal anchor through the anterodistal anchor using the FiberLoop from the anterodistal anchor (D). After the suture has been shuttled (E), the FiberWire from the anterodistal anchor is then shuttled through the posteroproximal anchor using the posteroproximal FiberLoop (F). The FiberWire from the posteroproximal anchor is shuttled through the anteroproximal anchor using the antero-proximal FiberLoop (G). Finally, the anteroproximal FiberWire is shuttled through the posterodistal anchor using the posterodistal FiberLoop (H). Permissions were obtained for this previously published figure by Hartigan et al.11
Miscellaneous
Labral Reconstruction
Labral reconstruction is indicated when our native labrum is not functionally viable to create the hip’s suction seal. With the pull-through technique,12 we prepare the acetabular rim by removing the nonviable labral tissue and burring the edges to stimulate a bleeding bony bed. The Knotless 1.8 Hip FiberTak Suture Anchor with #2 Suture, VE1 on the most anterior aspect of the acetabulum is used to fixate the anterior part of the graft, passing its sutures end through the shuttle suture. To fixate the reconstruction anchors, we pass the repair suture circumferentially around the graft, then into the joint to then retrieve it and pass it through the shuttle suture to fixate the graft. This is subsequently repeated until all the anchors have fixated the graft around the acetabular rim.
Labral Augmentation
This technique is indicated in patients that have a preserved chondrolabral junction but the native labrum is hypoplastic or insufficient to create the suction seal mechanism of the hip. Using the previously described technique,13 the acetabular rim is prepared on top of the native labrum placing anchors from medial to lateral as needed. The anterior part of the graft is attached to the anchor of the most anterior aspect of the acetabulum, by passing its suture through the shuttle suture. To fixate the augmentation anchors, we pass the repair suture through the chondrolabral junction into the joint to then retrieve it and pass it through the shuttle suture to fixate the hypoplastic labrum with the graft in an everted manner.
Capsular Reconstruction
Performing a capsular reconstruction is a complex procedure in the field of hip arthroscopy. A capsular reconstruction may be required and indicated in cases in which the capsule is needed to help increase joint stabilization but the patient’s capsular tissue is not sufficient to perform a plication or in the case of capsular insufficiency due to a previous arthroscopic procedure involving partial capsulectomy.
Following the previously described technique,14 the subspine cortical bone is located and 2 Knotless 1.8 Hip FiberTak Soft Anchors are inserted in the acetabular rim at the corners of the capsular defect, and then passed through the dermal graft using the shuttle mechanism. With the graft secured to acetabular rim, the remaining capsular tissue on the femoral side is secured to the dermal graft’s corners using a No 2. FiberWire suture (Arthrex) in a mattress fashion. Additional sutures are passed between the corners: medial, lateral, and distal. Also, additional anchors may be placed as needed.
Capsular Augmentation
Capsular augmentation is an indicated procedure when a repair or plication alone may not be sufficient to restore adequate joint stability due to poor tissue quality. Following the previously described technique, the subspine cortical bone is located and prepared for anchor insertion to posteriorly pass the repair suture through the dermal graft and secure it using the shuttle mechanism. Finally, the dermal graft is attached to the capsular tissue with simple stitches. This will avoid knot stacks, bridging the dermal graft to the insufficient capsule.
Femoral Head Remplissage
This procedure has been described to address cam deformity over-resection as a complication for arthroscopic femoroplasty developing subsequent microinstability. By following the technique,15 once the defect is located, measured and prepared, a Knotless 1.8 Hip FiberTak Soft Anchor is placed in the center of the defect. Afterwards, we pass the repair suture through the middle of the graft with a suture passer and then both the shuttle suture ends through another. Following these steps, a mattress configuration stitch is created, and the graft is evenly adhered to its desired position. We finalize by adding an additional 4 anchors into the corners of graft.
Discussion
The purpose of the present publication is to show the versatility of knotless tensionable anchors and the different possible scenarios in which it can be used to treat common pathologies found in sports medicine. The simplicity of the design allows surgeons to be more precise in an already complicated surgical area (Table 2). Having the possibility to approach all the previously mentioned procedures with only one type of implant makes for a more reproducible surgical scenario.
Table 2.
Pearls and Pitfalls
| Pearls |
| Load approximately 1 cm after the purple marking on the repair suture to ensure proper anchoring. |
| Following the trajectory of the repair suture with a suture retriever before shuttling to ensure smooth passage. |
| Pitfalls |
| Excessive or insufficient amount of repair suture through looped end can cause shuttling difficulties. |
| Soft-tissue bridge might interfere with adequate shuttling through the anchors mechanism. |
Another advantage to this implant is found in its small low-profile size (Table 3). Using a smaller diameter anchor decreases the bony footprint required for fixation, increasing the opportunity for multiple points of fixation within the existing surface area of bone−soft-tissue interface. This implant has not only proven to be a good resource, achieving satisfactory results at short-term outcomes in Bankart repair,16 it has also proven other benefits from its versatility, such as technical improvements with its retensioning ability,17 and its novel implementation as an alternative for posterior meniscal root repair.18 In conclusion, the use of a knotless tensionable anchor is a versatile, precise, and reproducible tool to address different scenarios in arthroscopy surgery.
Table 3.
Advantages and Disadvantages
| Advantages |
| Inserter-out device allowing an easier and swifter use. |
| Tensionable device, which allows the surgeon to adjust tension as needed during direct visualization. |
| All-suture implant, avoiding possible implant-related arthropathy. |
| Small diameter, which allows different points of fixation for the best construct necessary. |
| Linked constructs creating compression when needed. |
| Disadvantages |
| The anchor system is a suture-only design, not allowing the use of tape, if needed. |
Disclosures
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: This study was supported by Arthrex funding (IIRR-01609). B.G.D. is supported by the American Orthopedic Foundation. B.G.D. reports a relationship with Arthrex that includes: consulting or advisory, funding grants, nonfinancial support, and speaking and lecture fees; a relationship with Stryker Corporation that includes: funding grants and speaking and lecture fees; a relationship with Medacta USA that includes: nonfinancial support and speaking and lecture fees; a relationship with Orthomerica that includes: nonfinancial support; a relationship with Medwest Associates that includes: speaking and lecture fees; a relationship with HydroCision that includes: consulting or advisory; a relationship with Ossur that includes: nonfinancial support; a relationship with Stryker Endoscopy that includes: funding grants and nonfinancial support; a relationship with the American Hip Institute Research Foundation that includes: board membership; a relationship with AANA Learning Center Committee that includes: board membership; a relationship with Journal of Arthroscopy that includes: board membership; and a relationship with American Hip Institute that includes: equity or stocks. B.G.D. has a patent, “Method and instrumentation for acetabular labrum reconstruction,” with royalties paid to Arthrex; a patent, “Knotless suture anchors and methods of tissue repair,” with royalties paid to Orthomerica; a patent, “Knotless suture anchors and methods of tissue repair,” with royalties paid to DJO Global; a patent, Adjustable multi-component hip orthosis,” with royalties paid to Arthrex; and a patent with royalties paid to Medacta. A.C.L. reports a relationship with Arthrex that includes: consulting or advisory, nonfinancial support, and travel reimbursement; a relationship with Stryker Corporation that includes: consulting or advisory, nonfinancial support, and travel reimbursement; a relationship with Medwest that includes: nonfinancial support and travel reimbursement; a relationship with Smith & Nephew that includes: nonfinancial support and travel reimbursement; a relationship with Vericel that includes: nonfinancial support and travel reimbursement; and a relationship with Zimmer Biomet that includes: nonfinancial support and travel reimbursement. A.C.L. is Medical Director of Hip Preservation at St. Alexius Medical Center and a clinical instructor at the University of Illinois College of Medicine. All other authors (P.A.P., J.S.O., W.T.H., P.W.S.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Supplementary Data
This video displays the versatility of knotless pensionable suture anchors. First, we’ll describe the inversion technique for a hip labral repair, where the anchor is placed along the acetabular rim. In this case, we are going to utilize the loop end of the shuttle suture to position it around the chondrolabral junction. And once this is done and brought out through a working cannula, we then grasp the repair stitch of the anchor, which is the blue and white stripe suture, right here, and feed it through the loop. When we tension this anchor, what you’ll see is the labrum actually inverting toward the femoral head—very useful in say, a smaller volume labral tissue. In contrast with an eversion technique, which is standard, we will place the anchor no differently in the bone and remove the shuttle sutures through an alternate portal. We then take the labral repair stitch, drive it through the chondrolabral junction, and grasp that through the working portal as shown. We then will go and get the loop end of the shuttle suture. And when this is tensioned, we will then see how the labrum everts toward the anchor, as seen here. So very versatile and can be used in alternating fashion or independently when needed. Next, we’re going to describe the inverse hip labral repair, meaning in shoulder fashion we’re placing the anchor anterior, or along, the chondral surface similar to a shoulder. We will then use a passing device to grasp the repair stitch behind the labrum, and once this is done, we’ve essentially performed an inversion style stitch due to the positioning of the anchor. So simply grab the shuttle suture and the repair stitch and tension it down to one's liking and we cut flush to remove any suture tail, as shown. Next the suture-staple gluteus medius repair is done in partial undersurface injuries. 2 anchors are placed along the trochanter. Suture repair from #1 is then passed through the loop end of suture #2 and vice versa. So, in crisscross fashion we will then tension the anchors, so you perform a suture-staple configuration as seen here, providing an excellent approximation of undersurface injury. Next, in a labral reconstruction with all suture anchors placed along the acetabulum, a labral graft is being brought in and from an anterior to posterior direction, we simply utilize the eversion technique with the graft tissue being laid down along the acetabulum sequentially with reproducible, tensionable fashion as shown. With each progressive anchor, fixation does really provide a nice approximation of graft tissue along the acetabular junction and afford us an excellent labral seal at the end of the case, as seen here. In the labral augmentation case, we will do the same steps, however we will pass each individual repair stitch around the native labral tissue, performing a nice reapproximation of the native tissue against the graft to perform an excellent labral seal with the chondrolabral junction intact.
References
- 1.Goble E.M., Somers W.K., Clark R., Olsen R.E. The development of suture anchors for use in soft tissue fixation to bone. Am J Sports Med. 1994;22:236–239. doi: 10.1177/036354659402200214. [DOI] [PubMed] [Google Scholar]
- 2.Visscher L.E., Jeffery C., Gilmour T., Anderson L., Couzens G. The history of suture anchors in orthopaedic surgery. Clin Biomech (Bristol, Avon) 2019;61:70–78. doi: 10.1016/j.clinbiomech.2018.11.008. [DOI] [PubMed] [Google Scholar]
- 3.Loutzenheiser T.D., Harryman D.T., Yung S.W., France M.P., Sidles J.A. Optimizing arthroscopic knots. Arthroscopy. 1995;11:199–206. doi: 10.1016/0749-8063(95)90067-5. [DOI] [PubMed] [Google Scholar]
- 4.Meier J.D., Meier S.W. Over-pointing technique: An approach to past-pointing arthroscopic knots on alternating suture posts without alternating the knot pusher. Arthroscopy. 2007;23:1358.e1–1358.e3. doi: 10.1016/j.arthro.2007.03.011. [DOI] [PubMed] [Google Scholar]
- 5.Benca E., Dlaska C.E., DiFranco M.D., et al. Biomechanical comparison of knotless vs. knotted suture anchors in the acetabular rim with respect to bone density. Clin Biomech (Bristol, Avon) 2020;74:21–26. doi: 10.1016/j.clinbiomech.2020.02.005. [DOI] [PubMed] [Google Scholar]
- 6.Rhee Y.G., Ha J.H. Knot-induced glenoid erosion after arthroscopic fixation for unstable superior labrum anterior-posterior lesion: Case report. J Shoulder Elbow Surg. 2006;15:391–393. doi: 10.1016/j.jse.2005.03.010. [DOI] [PubMed] [Google Scholar]
- 7.Barber F.A., Lee Evanson J.R. Editorial Commentary: Acetabular labral repair—is a knotless anchor better? Arthroscopy. 2019;35:77–79. doi: 10.1016/j.arthro.2018.09.003. [DOI] [PubMed] [Google Scholar]
- 8.Willemot L., Elfadalli R., Jaspars K.C., et al. Radiological and clinical outcome of arthroscopic labral repair with all-suture anchors. Acta Orthop Belg. 2016;82:174–178. [PubMed] [Google Scholar]
- 9.Ergün S., Akgün U., Barber F.A., Karahan M. The clinical and biomechanical performance of all-suture anchors: A systematic review. Arthrosc Sports Med Rehab. 2020;2:e263–e275. doi: 10.1016/j.asmr.2020.02.007. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Mazzocca A.D., Chowaniec D., Cote M.P., et al. Biomechanical evaluation of classic solid and novel all-soft suture anchors for glenoid labral repair. Arthroscopy. 2012;28:642–648. doi: 10.1016/j.arthro.2011.10.024. [DOI] [PubMed] [Google Scholar]
- 11.Hartigan D.E., Mansor Y., Perets I., Walsh J.P., Mohr M.R., Domb B.G. Knotless “suture staple” technique for endoscopic partial thickness abductor tendon repair. Arthrosc Tech. 2018;7:e975–e980. doi: 10.1016/j.eats.2018.06.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Perets I., Hartigan D.E., Chaharbakhshi E.O., Walsh J.P., Close M.R., Domb B.G. Circumferential labral reconstruction using the knotless pull-through technique—surgical technique. Arthrosc Tech. 2017;6:e695–e698. doi: 10.1016/j.eats.2017.01.014. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Maldonado D.R., Chen J.W., Lall A.C., et al. Hip labral augmentation with tibialis anterior tendon allograft using the knotless pull-through technique. Arthrosc Tech. 2019;8:e1209–e1216. doi: 10.1016/j.eats.2019.06.010. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Byrd J.W.T. Hip Capsular reconstruction made easy: The timing and the technique. Arthrosc Tech. 2021;10:e73–e78. doi: 10.1016/j.eats.2020.09.012. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Frank J.M., Chahla J., Mitchell J.J., Soares E., Philippon M.J. remplissage of the femoral head−neck junction in revision hip arthroscopy: A technique to correct excessive cam resection. Arthrosc Tech. 2016;5:e1209–e1213. doi: 10.1016/j.eats.2016.07.012. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Tross A.K., Nolte P.C., Horan M.B., et al. Short-term outcomes after knotless all-suture anchor Bankart repair. Obere Extremität. 2021;16:27–33. [Google Scholar]
- 17.LeVasseur M.R., Mancini M.R., Williams N., et al. Ability to retension knotless suture anchors: A biomechanical analysis of simulated Bankart lesions. Orthop J Sports Med. 2022;10(6) doi: 10.1177/23259671221098726. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Mesquita Queirós C., Amorim-Barbosa T., Fonte H., Silva A. Knee meniscus posterior root repair with FiberTak. Arthrosc Tech. 2022;11:e471–e474. doi: 10.1016/j.eats.2021.11.020. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
This video displays the versatility of knotless pensionable suture anchors. First, we’ll describe the inversion technique for a hip labral repair, where the anchor is placed along the acetabular rim. In this case, we are going to utilize the loop end of the shuttle suture to position it around the chondrolabral junction. And once this is done and brought out through a working cannula, we then grasp the repair stitch of the anchor, which is the blue and white stripe suture, right here, and feed it through the loop. When we tension this anchor, what you’ll see is the labrum actually inverting toward the femoral head—very useful in say, a smaller volume labral tissue. In contrast with an eversion technique, which is standard, we will place the anchor no differently in the bone and remove the shuttle sutures through an alternate portal. We then take the labral repair stitch, drive it through the chondrolabral junction, and grasp that through the working portal as shown. We then will go and get the loop end of the shuttle suture. And when this is tensioned, we will then see how the labrum everts toward the anchor, as seen here. So very versatile and can be used in alternating fashion or independently when needed. Next, we’re going to describe the inverse hip labral repair, meaning in shoulder fashion we’re placing the anchor anterior, or along, the chondral surface similar to a shoulder. We will then use a passing device to grasp the repair stitch behind the labrum, and once this is done, we’ve essentially performed an inversion style stitch due to the positioning of the anchor. So simply grab the shuttle suture and the repair stitch and tension it down to one's liking and we cut flush to remove any suture tail, as shown. Next the suture-staple gluteus medius repair is done in partial undersurface injuries. 2 anchors are placed along the trochanter. Suture repair from #1 is then passed through the loop end of suture #2 and vice versa. So, in crisscross fashion we will then tension the anchors, so you perform a suture-staple configuration as seen here, providing an excellent approximation of undersurface injury. Next, in a labral reconstruction with all suture anchors placed along the acetabulum, a labral graft is being brought in and from an anterior to posterior direction, we simply utilize the eversion technique with the graft tissue being laid down along the acetabulum sequentially with reproducible, tensionable fashion as shown. With each progressive anchor, fixation does really provide a nice approximation of graft tissue along the acetabular junction and afford us an excellent labral seal at the end of the case, as seen here. In the labral augmentation case, we will do the same steps, however we will pass each individual repair stitch around the native labral tissue, performing a nice reapproximation of the native tissue against the graft to perform an excellent labral seal with the chondrolabral junction intact.