Name: PASTA SutureBridge™
Uploaded: 2011-04-12T00:00:00Z
Channel: Arthrex

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video

VID1-003546-en-US | A | PASTA SutureBridge™

Stephen S. Burkhart

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

Eine Videoaufnahme einer Operationsanleitung an einem lebenden Patienten oder Patientin in einem Operationssaal oder eine Demonstration an einem Humanpräparat.

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PASTA SutureBridge™

This is a 56 year old female. This is her dominant right shoulder we're operating on. She fell about a year ago and landed on her right hip, and her right arm fractured her hip but injured her shoulder. And now the hip is all healed. She's continued to have shoulder pain, and the MRI shows she's got a torn subscapularis and a subluxed biceps. So let's have a look at this. She's got a bit of a mess there. She's got a lot of fraying. It's a little hard to tell where it's all coming from here. She has some fraying in the cuff. She obviously had some tendinosis. She probably has, or may have a partial tear on the articular surface. That is a possible lesion. She's definitely got a big flap of biceps tendon right here that's sort of obscuring her vision. So. We'll look kind of around the corner at her subs GAP. She's got some tearing of the upper sub scalp. Now give me a posterior lever. Push. So Tom is going to stabilize the elbow and push posteriorly on the proximal humerus. And that's going to open up so that we can see the footprint. And you see there's some disruption of fibers in the upper sub scalp. There's going to be some bear footprint there too I'm sure. Okay. But we'll come back to that. So relax. We'll look at the labrum all the way around. Just a little bit of fraying posterior on the labrum. Okay. So here we are preparing our bone bed for the posture repair. And give me a small curette. At. So we're coming in through the Antero-superolateral working portal. Okay, so now we've got a nice footprint bone bed preparation here. Okay, now let's have that cannula again. That's good. So I'm going to show you how I typically do these. And what you want to do is to come adjacent to the lateral margin of the acromion, and you want to get an anterior anchor. Through the anterior part of your supraspinatus, basically. And come into the footprint there. And then we're going to do what we call a double pulley repair. So that would be just about just about perfect there. Let's have a knife. Now what we do the way we have this arranged, we have a metal cannula that's big enough for the for the 4.5mm Bio-Corkscrew or the bio composite Corkscrew. But what I like to do is have a sharp point that will help me go through the tendon. So we have the larger bio punch that fits just snugly through here. But this is not the punch that we're going to use for the actual anchor. So once we've got the cannula through with this, then we'll take the large punch out and put the small one in. But you see, it doesn't really fit well. It has a real loose fit inside this cannula. So you can't use it to put the cannula in. You just have to use the larger diameter punch for that. So what I'll do is go in this basically the same angle as the spinal needle that I put in. And I want to come in perhaps at the cable or thereabouts near the anterior part of the cable. Okay. I think that's going to be just about perfect. And then we want to then push our cannula down around it okay. So now pull the punch out. Now let's place our place our cannula where we want to have our anteromedial anchor. Our anterior anchor, I should say. Okay, so let's put it right there. Let's look at that. Okay. That's just about perfect. Let's go. Okay. So that's our Bio-Post. Okay. And I just what I'll spin this and get an idea of how dense that bone is and whether I need to tap it. Because if it is real dense bone, I will tap it. I think we're fine without tapping on this one. So what we're using is a we're using the bio composite Corkscrew here 4.5mm. And it feels like it's going easily. If it does start to go very with a lot of difficulty, then we can back it out and tap it then. But you don't want to break one of these if you can help it. Okay, so we're down as far as we need to be. And so by going transcendent now you see, we've got all four limbs coming through the same spot in the rotator cuff. Okay. That's an important thing to remember because we're going to do a double pulley repair between these two anchors. Now let's have the needle again. So now I want to place another trans tendon anchor. But I've got to go more posterior this time. It looks like it's going to be pretty good there. Okay. That should be just about perfect. And so now we'll do the same thing here. I want to go in the same line of same angle of approach as that posterior needle. And then. Let's see where that's gotten us. Okay. Needle out. Okay. So the punch is in there. Now we just need to have to bring that cannula down around it okay. Pull the punch out. Now let's set it where we want it. And now we'll put the small punch in. And that's going to be perfect. Go. Okay. That's good. So that first laser mark is for the fully threaded composite Corkscrew. Okay. Let's take let me just feel it. I'm going to spin it around some. It doesn't feel like we're going to need to tap. You can get a good feel for the density of the bone just by spinning your punch. Okay, so now we've got this bow composite Corkscrew that we'll put in. A 70 degree scope is invaluable for this. You have tight spaces. You need to be able to look around the corner. And it's so much easier with a 70 degree scope. Okay. And now we'll take the cannula out. Now you can see these two anchors the anterior and the posterior. And what we're going to do is just pull that bridge of tendon down between the two anchors and put a double mattress suture. And then we're also going to bring that out laterally to compress it like a SutureBridge. We call that a pasta bridge. Okay. So now we go back up subacromial. So you can see now Subacromial. This is our anterior set of sutures. That's our posterior set of sutures. And you can see how we're coming. Right. Exactly. Adjacent to the edge of the acromion on the lateral edge. So that's the absolute best angle I could have gotten. So now we're going to do our repair. We want to pull that tendon bridge down between these two anchors. So we'll take a suture from each one. Let's start out with a tiger's. Good. So we'll take one tiger from each anchor. And we're going to do our double pulley repair. Okay. Hold this. And I'm going to tie six throws. 123456. And we'll test it from above and from below to be sure it doesn't slip. And now I'm going to cut leave about a four millimeter tail cut. Okay. So pull that down. Sorry. It's okay okay. So you see how that is going to really establish the medial aspect of our footprint there okay. So now we'll do the same thing grabbing the other two limbs or the TigerWire. Okay. Pull the cannula back a little. It's too far. Now at this point, even if you wanted to a sliding knot. You couldn't. It wouldn't work. The reason it won't slide is because that knot that we just tied has it fixed. Okay, so what I want to do now is I want my post limb to be above the anterior anchor because the knot came down over the post anchor. So I'll have a knot on each end of that tendon bridge. Okay. Cut this here. So now I'm going to tie this as a static knot. Six throws. So there's our first one. Got to get the twist out. As we come down we'll do three half hitches in the same direction. Then we'll flip the fourth one. Come down like this. We slip the knot, push her off, and we differentially tension to flip that. The fifth one we don't flip. And the sixth one we're going to flip again. Hand. Like so. Okay, now let's have the cutter. All right. So now we're going to do the same thing with our blues. We'll take a blue from the anterior anchor. And we'll take a blue from the posterior anchor. And we'll tie these together before I tie them together I want to be sure they're going to slide that one slides okay. That one slides okay. All right. So six throws. And then we'll pull from below to be sure it doesn't slip. And we're not going to cut this one. We're going to keep these long okay. So now we're going to pull the knot down. And then we'll pull those two suture limbs up. So now we'll take the The remaining suture limb from the anterior and the remaining blue suture limb from posterior, and tie those together. [00:13:14] To do this. Now the the first knot came to the to the front of the tendon bridge. So I want the second knot to come to the back. And we'll use these blue limbs to do a SutureBridge inside to or a pasta bridge. Okay. Take this. Cut this. Okay. So now we're ready to do our bridging maneuver. Let's get these out of the way first. Okay. So now we're going to criss cross these into this pasta bridge configuration. So take one limb from the front, one limb from the back. And I'll use my lateral cannula to find a spot where I want to put an anchor. That's going to then compress this tendon over the lateral part of the pasta bridge. So that's pretty good right there. Okay. Right there. Tap it. Now this will be a swivel lock that we put laterally. So we'll thread these two sutures through the eyelet of our swivel lock. Now we'll take that punch out. Back the cannula back a little bit so I can see. Okay. Now we'll get it down even with the bone. And now we'll insert it. These are the vented biocomposite anchors. Keep going. Stop. And now I can turn my thumb piece Clockwise. And be sure that I'm all the way down because that backs off that green sleeve. Okay, so now we took out the safety stitch, and now we cut these two sutures. Okay. And now we take the suture retriever. And now we want to place a posterolateral anchor utilizing the remaining two blue sutures to compress the footprint down. And once again, I can use this clear cannula to pick out a spot, kind of in the metaphyseal part. Okay. Internally rotate a little bit. Okay. Right. That ought to be a little more stop. That ought to be just about perfect okay. [00:15:58] Put it in there. Okay. Hit it. Okay. Okay. The whole attention on those and pulled the punch out. Okay, relax. Let me put that down. And now turn. Okay. Hold it and we'll see if we're down or slightly countersunk. Okay, now take the safety stitch out. Take the driver off. Let's have the suture cutter. So we'll take out the safety stitch. We'll cut these two remaining blue tails. Okay. So now you see we've got this very nice compressive footprint. For our pasta repair. We call this a pasta bridge. And you see how we've really compressed down the medial footprint. And I think that does a couple of things. It provides the compression you need for healing, but it also basically restricts the synovial fluid from the tendon bone interface. So kind of waterproofs that whole thing. And you know, all of the research for many, many years has shown you don't want to have synovial fluid in that interface if you can help it. So I think that's exactly what this lady wanted to have done. We'll look back inside. So now you see how we have a very nice anatomic footprint that's been reconstructed. And basically it looks like a normal rotator cuff there. If you didn't know it had been torn, it'd be pretty hard to tell it now. You see, it has good rotational control too. Nothing lifts off when you rotate the arm. So that looks good. And then you see here more anteriorly. That's where we repaired our sub GAP. And we've got supra and infra here where the pasta repair was done.

PASTA SutureBridge™

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