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DVD-1090_008 | A | Double Pulley Trans-Tendon PASTA Repair Using Bio-Corkscrew® FT Anchors

Stephen S. Burkhart

Human

A video recording of a surgical technique on a live patient in an operating room setting or a cadaveric demonstration.

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Double Pulley Trans-Tendon PASTA Repair Using Bio-Corkscrew® FT Anchors

So a rotator cuff is intact on the bursal surface. So we've got a clear view. That's the kind of view we're going to have when we come up to tie the knots. We've debrided all the Bursa off the top of the cuff tendons, particularly the supra and infraspinatus, because our trans tendon anchors are going to go through those two tendons. So now we're ready to go back inside the joint. We put our cannula back intra-articular through the anterior portal, just in case. We need to do some suture manipulations here. But generally we don't have to at this point because what we're going to do is a trans tendon repair. And what we want to do is come in just lateral to the acromion. And I'm palpating where the lateral acromial edge is right now. And I'm going to want to come in through the tendon toward that anterior part of the bone footprint. So you notice we have the arm at about 30 degrees or so. Now you're going through the tendon, the tendon obliquely. You've got to imagine that on the top surface of the tendon you're starting out more lateral. So to get this as anatomic as anatomic as possible. We enter the articular surface a little bit medial to the articular margin. And we'll drag it back here. So we have a little more tendon substance to work with. And then we'll plan to put another second anchor more posterior. All right. So now we're going to do a percutaneous portal here. We're going to walk this punch right next to the anchor. And then we'll just bore right through our cuff. Of course we don't want to damage the articular surface when we do this either. And we leave our needle, we'll just withdraw it back a little bit, but we'll leave it there because we may need it as a guide once more. Then our anchor is going to have to find that same channel through the tendon. So we'll withdraw this back. We'll come right to the articular margin right there. Okay. We're going to punch the hole. And this will be our anterior anchor. Fairly hard bone in this young lady here. If we go to the top of the laser mark. Now we're going to do kind of a of a quick exchange here, and I'm going to be right there ready to come in right at that same angle right behind him. And that will hopefully optimize my chances of finding that same little channel in the cuff. And we can twist it through. And here it comes. Okay. This is a fully threaded Bio-Corkscrew. So now we're going to just go ahead and insert this. You notice we didn't tap with this fully threaded Bio-Corkscrew. I generally don't tap because you have a lot of torsional strength with this inserter that actually is inside the body of the anchor as you insert it. So you don't worry about stripping it like you used to with the other other designs that had the hex head on top. So that's a good bite right there. So we insert it to the top of the laser line there. Okay. So now we're going to pull the inserter out. You see that that anterior anchor is at the very front of this pasta footprint. So now I want to put another anchor back posterior. We're using a using a 70 degree scope to be sure and see this best possible. Another thing you need to think about is at what point do you repair a postal lesion? The the old conventional wisdom is that you repair one that's 50% of the thickness of the rotator cuff. But it's it's difficult to measure that. If you look at on average the rotator cuff is about the footprint is about 15 or 16mm in width. And according to Curtis this study, it can range between 12 and 21mm from medial to lateral. So this lady is kind of average size I would say hers is 15 or 16. We've got a four millimeter footprint. So this is about a 25% maybe 30% footprint disruption here. But I think in a young person you need to repair 30% one. So that's just my ballpark estimate of when you need to repair it. Okay. So now you see we've got our anterior sutures for suture limbs in the front for suture limbs in the back. And the next thing we're going to do is go up, and we're going to tie those in the subacromial space. And just to give you an idea of what we're going to do, we're going to tie the suture pairs from the front anchor to the suture pairs from the back anchor with what we call a double pulley technique. So, for example, on the blue sutures, we'll tie a blue one from the front to a blue limb from the back, then pull that down on the cuff and then tie a static knot with a knot pusher inside the shoulder at that point. So let's go back up into the subacromial space. I still have my 70 degree scope in because I feel like I can see better with it. So I'm going to put a lateral working cannula in here. This is an 8.25mm clear cannula. Now you have to sort of imagine when you look at the change in angle of your arm, when you bring the arm into more abduction, the angle of your bone footprint is greater. It's a greater angle. It's at a tilt. When you bring it down this way, it flattens out the angle of your bone footprint. So ideally you want some traction and an angle, something like that when you actually tie the sutures. We'll start out with the blue sutures, and we'll take one blue from the anterior anchor. Bring it out through the through the lateral portal. We'll take one blue from the posterior anchor. Bring it out through the lateral portal. We'll tie it over. Just a rigid metal post. In this case, we've got a KingFisher suture retriever. And what I'm going to do is tie a six throws six half hitches. Again, because we've shown in the lab that's the most secure knot. And then we'll tension it from the undersurface two to be sure it's not going to slip. And we'll just leave a little four millimeter tag on the end of the knot. Then what we do is we'll take the blue limbs that come out through our insertion portals, and we're going to tension them, and we're going to pull the knot down onto that tendon bridge. We'll watch inside the joint as that knot comes down right over the tendon. We've now got a tendon bridge there between the two anchors right over the top of that bear foot print. So now what I'm going to do is pull those sutures out the two remaining blue limbs that we just tensioned. And now we're going to tie a static knot. We'll use a six finger knot pusher. And you see how we have our angle of pull is down at about 10 or 20 degrees. So that it flattens out the footprint to a horizontal position as we tie this knot. As we come down with our knot, we've got to get the twists out. So I'm rotating the plastic portion of the knot pusher to get that twist out, and then we'll just push down and really tension that to get it to lie down right against the footprint. The great thing about this knot pusher is that you can shift soft tissue where you want it. You can push tissue into a point, you can pull tissue to a point. And so that's what we're doing is we're tensioning this as we go, pushing the soft tissue right down over the bone bed so that at the end what we want is as an indicator of good loop security. What we want to see is that this tissue is indented over the top of that tendon bridge. So we've got three half hitches down. This will be a flip. So you can flip the post without having to rethread. And we'll release tension in our post pull tension and our wrapping limb. And you see our post has switched. So we've switched post without having to rethread. And now we use our open ended FiberWire cutter to come in and cut the suture. It's quicker than the closed ended one. Leave about a four millimeter tag. So now let's look critically at that and see how we have nice nice compression. You might wonder what happens if these sutures were twisted or crossed down at the base, at the eyelet. I've never seen a situation where they wouldn't slide with this technique. So even if you ended up with, obviously we're doing this somewhat blind because we're we can't look inside the joint and in the space at the same time. They always slide in my experience. Now we're going to tie this knot outside the body again. And then we'll pull on these free limbs again to pull the knot down over the top of that tendon bridge right there. Now you realize because of the fact you've tied that knot, now you're committed to have to tie a static knot here. If you tried to tie a sliding knot, there's no way it's going to slide. So that's one thing you have to keep in mind. So what you see here is on this tendon bridge. As you look at it, we are about 2 or 3mm lateral to the Musculotendinous junction, which we know is exactly the point where the medial part of the bone footprint needs to be reattached. Whether you're talking about a pasta repair or a double row repair. That's where we always try to put our medial row sutures through the tendon. So what we end up with is two sets of double mattress sutures, and we tie the second set of double mattress the same way as we did the first. Let's take a final look from a subacromial perspective. Now you see this medial footprint reconstitution that we've got here. It's 2 or 3mm lateral to the musculotendinous junction. It's analogous to a double row repair, except that our lateral row is the patient's own natural attachment, which hadn't come loose. So now we're going to do a double check back inside the joint. And be sure we're satisfied with the way it looks. So you recall the exact area where we had bear footprint before. Our cuff goes exactly out to the articular margin. We've got great coverage, anatomic coverage now of our bear footprint. So that's how we do the double pulley trans tendon posture repair.

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