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VID1-003518-en-US | A | Sixth Finger Knot Pusher

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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Sixth Finger Knot Pusher

This is the sixth finger knot pusher. And you see, this is a double diameter knot pusher that has an inner cannulated metal cylinder, and then a sliding plastic cylinder that pushes the half hitches down sequentially. There's a disc at the top that you can use to help control the tension in your post. The suture that's threaded through the inner cannulation is going to be the post, because it's the one under tension, so that once it's threaded through, you'll be able to grab it on this end and use your hand to control the tension up through the cannulation. Okay, so the first thing I want to do this is the upper SpeedScap. So I want my knot to come on the soft tissue side. So I'll pull on one and then the other suture limbs. Obviously this is our soft tissue side. That's the one I want to be the post because I want my knot to come down on that and the knot will come down on the post. The way we thread this is to put the suture through the nitinol threader, and then we thread that by pulling as we push the tube down into the cannula. Now, the way that I what you have to do at this point, you have to be able to control the tension in your post. I will wrap the post suture around my fingers and the way I do it is I will. I will hold between my index and thumb, and then I wrap it as almost a pulley around my little finger, around the back of the fifth and fourth, and then a pulley again on the third. And that allows me to push on the disc to pull on the disc, but yet also to tension back on the suture to control the the sutures tension. An alternative way that you might find easier is to get a hemostat and place it back here and use your hemostat for counter traction or counter tension. So you're going to hold that in your hand, and then you can push and pull and you just adjust that where it's comfortable. I think if you're just beginning this that might be an easier way to do it. Now on your other limb, you the ideal length to have is just an inch or so beyond this disc. And that will give you a length of suture that's not redundant and it's not getting in your way. So you want to pull tension on your post, and you can see how you actually can transport the tissue over to the top of your anchor. And that's a feature that you can't do with a standard knot pusher. Then you'll use your. In my case, I'm right handed. I'm going to put a series of underhand half hitches. So we'll push that down. And so now we're just pushing our half hitches down. This is our first half hitch. And you see as we get close to the end we pull our metal cylinder back so that that half hitch can go past it. And now we can hold the end of that knot pusher down there, just like a kid holding his finger on a shoelace when he ties a shoelace back when they used to tie shoelaces. So now here we have another half hitch coming down. We get it almost to the end, right there again, and we pull back slightly on the metal cylinder and immediately pass point. That's our second one. We do three underhand half hitches, so we'll do a third one. Now I'm going to I'm going to show you how to get a twist out. I'm going to intentionally have this one come down with a twist. I'm sort of wrapping it around and you see how it comes down with a twist. If you put it down that way, you're going to going to have slack between your throws and you'll have a loose knot. So you have to just spin your whole knot pusher both cylinders to get that twist out, and then you continue on down and you can just go past your knot pusher as you back it out and then pass point again. So that's three half hitches. Now the next hitch is our fourth half hitch. And we want to we want to flip the fourth throw. That is we want to reverse the post. So now we come down. We're coming down straight. So there are no twists. So now we're going to get within about a centimeter of the end of the knot pusher. Then we'll back the whole assembly off. And you can see that we have two suture limbs. The one under tension as the post. The other one is the loop. Now I'm going to release tension in the post limb and pull tension in the loop limb and watch what happens. See, now the loop became the post and the The post became the loop. Not only that, it flipped from an underhand throw to an overhand throw. So it increased internal interference, or not in two ways by changing the post to the other lamb, and by changing the direction of the throw from underhand to overhand. Now our fifth one, we bring down without without a flip. Now, you see, we're getting a little half twist here. So we've got to spin our knot pusher to to get it out. Now I'm going to, I'm going to spin it the other way. So I have a twist again. And you see the other way that I can get that half twist out is to just unwrap the suture from around the knot pusher, and then that automatically brings it down straight. Okay. You have to of course wrap it the correct way. If not, you'll, you'll if you wrap it the wrong way, you'll get even more of a twist. So this one we come down and we pass point. And then our sixth throw, we're going to flip again. So we come down and just like before, we're going to back our not pusher off and we're going to flip our throw like so. And we pass point like so. Now one little pearl on the last throw that will make it less likely to unravel your knot. You see, I've done a total flip here, but I can actually make it a half flip by sort of differentially tensioning back the other way. And you want at the end for the tension to be equal in the two limbs. So it ends up as a square half hitch. And you know that when the two limbs look about like rabbit ears, that is, they're they're each coming up at about the same angle, like a rabbit ear. Like like the two rabbit ears. So that's pretty close there to being equal tension. And that is the least likely to unravel. When you get equal tension on the end, you bring down that last throw as a square throw. So that's kind of advanced sixth finger knot tying there. Okay. So now we're using the traction stitch from the eyelet of the anchor of the SwiveLock to reduce this dog ear and to get a little more footprint that's compressed down. [00:07:39] There. So you. See, the other thing you can do is very carefully control the amount of tension you're placing. Because if you did a sliding knot and it wasn't sliding well, you just would have to pull as hard as it took to pull it through the tissues. And plus you might cut the tissues here. We've got four soft tissues. [00:08:16] This is the flap. The fifth one comes down without a flip, and then the sixth one will have a flip. And then we get the rabbit ears here. So we have equal tension both directions. And we want to end up with more or less a half flip so that we have the rabbit ears. Okay.

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