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Arthrex presents the SutureLoc™ Implant Series of the BreakThrough program. This collection features all five of the BreakThrough episodes detailing case presentations, surgical demonstrations, scientific literature review, and panel discussions highlighting the SutureLoc implant. Joining host Christopher Adams, MD, are in-studio guests Aaron J. Krych, MD (Rochester, MN); Walter R. Lowe, MD (Houston, TX); Justin J. Mitchell, MD (La Crosse, WI); and Patrick A. Smith, MD (Columbia, MO).&nbsp;

BreakThrough™ With Christopher Adams, MD: SutureLoc™ Implant Series

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Arthrex presents the SutureLoc™ Implant Series of the BreakThrough™ program. In this episode, leading surgeons provide insight into the innovative use of the SutureLoc implant for meniscal root repair and review relevant scientific literature. Joining host Christopher Adams, MD, are in-studio guests Aaron J. Krych, MD (Rochester, MN), and Justin J. Mitchell, MD (La Crosse, WI).&nbsp;

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BreakThrough™ With Christopher Adams, MD—SutureLoc™ Implant Episode 1: Innovative Solutions

Welcome to breakthrough. Today we're going to be discussing the use of the suture lock implant for meniscal root avulsions with Erin Krich from Rochester, Minnesota, and Justin Mitchell from La Crosse, Wisconsin. Gentlemen, thank you for joining us. Thanks for having us, Chris. Thanks, Chris. Absolutely. Now, Erin, to start off, can you give us a brief historical view of how we approach meniscal root tears in the past? Yeah, Chris, I think it's really been a rapid revolution. First, we really didn't understand what a root tear was prior to 2008. We then learned very early on that if we just remove that portion of the meniscus, patients have deleterious and disastrous consequences. We then looked at our non-operative outcomes. And really at long term, they also did very poorly. So this led to the transtibial pull through repair techniques. And while these techniques have produced some very good results, I think now we're really at the next phase of innovation with direct suture anchor repair. Justin, can you talk to us about where we are now in our approach based off of recent evidence based medicine? Yeah, absolutely. Let's take a look at the data. So as we've discussed, Non-operative management of posterior medial meniscus root tears leads to unacceptable long term outcomes. We've seen poor clinical and radiographic outcomes with long term non-operative management. At a minimum, ten year follow up, 37 of 39 patients in this study had failed this non-operative treatment. A majority of patients also went on to arthroplasty. We see, however, that early biomechanical data demonstrates improvement and ability to restore normal biomechanics of the knee with transtibial meniscal root repairs. And in this prospective consecutive clinical outcomes, following patients over two years or more, we can see that transtibial root repair for medial and lateral root tears improves outcomes at two years postoperatively. Interestingly, increased age, increased BMI, cartilage status, and meniscal extrusion did not necessarily have a negative impact on short term functional outcomes. However, age greater than 50 years in extrusion did negatively influence patient activity level. Despite these positive outcomes, our available data is inconsistent. Several studies demonstrate positive outcomes while others are more guarded. This editorial commentary even suggests that repairs are at the level of a salvage procedure. Because of that, it does appear as though there is an opportunity to improve our outcomes. So we have to ask ourselves does modifying our technique matter? I would submit to you that the answer is yes. In this study examining the efficacy of meniscus root repair, we see that generally improved outcomes are seen. But up to 6% of patients progress to some degree of arthritis. This study looked at modifying the technique for meniscus root repair. They compared an all inside technique versus the traditional transtibial technique. They found that an onside technique with joint line fixation more regularly approximating normal anatomy, had significantly improved outcomes when compared to a transtibial technique at two years follow up. The Transtibial pullout repair group did not have significantly improved Tegnér scores at two years and post-operative extrusion ratio increased in both groups, but the change in the extrusion ratio was significantly reduced in the all inside group. Post-operative MRIs also revealed significantly improved healing rates in the all inside group. This suggests that an all inside technique or joint line fixation may benefit us and improve our technique. So then we ask, does the ability to retension the meniscus matter, or the ability to get this meniscus to stay anatomic? In this study they tested several different suture configurations. They found that all suture configuration types displaced to some degree. And while all techniques demonstrated ultimate failure loads that were above the currently accepted rehabilitative force threshold, this displacement is still of some concern. This is especially in combination with the second study, which demonstrated that loosening of transtibial pullout meniscal root repairs was unrecoverable. The study showed that significant unrecoverable loosening occurred during rehabilitative loading during double tunnel transtibial meniscus root repairs. They also found that root repairs gradually displaced with continued loading instead of reaching an equilibrium such that when cyclic displacement occurs, it is not static and can continue. This leads us to ask if pretensioning and joint line fixation matters, especially to improve our biomechanics and joint line fixation. We know that there are significant biomechanical consequences of non anatomic meniscal repair. We know that achieving an anatomic repair significantly reduces our contact area and more closely approximates our normal knee. Non anatomic repairs, however, result in increased mean and peak contact pressures of 13 and 26% respectively, which does not approximate a normal anatomic situation. This can lead to joint degeneration and put our cartilage at risk. So we must get it anatomic and we must keep it there. Now Aaron, you recently published a paper on different suture configurations and fixation type. Can you explain your findings to us? First of all, we wanted to design a biomechanics study that replicated real life and post-operative rehabilitation. And in that biomechanics study, we compared overall the transtibial pull through repair technique with direct suture, anchor retention, double fixation. What we found in that study when we compared the two techniques was first, the strength of compression was greater for direct suture anchor fixation compared to the transtibial, which makes sense. You're fixing it a farther distance away from the joint line. And then secondly, we found that when you took the knee through cyclic loads, there was more cyclic displacement with the transtibial pull through technique than direct suture anchor fixation. When we looked at the actual suture configuration, we also found that that makes a huge difference. And the more degenerative meniscus tissue that we have, the more a locking type of construct with a mason Allen type of procedure did better than locking loop techniques. It's interesting to see the power the suture configuration can have on the strength of the construct. Great research. Justin, what do you think is the biggest advantage of suture lock in these root tear scenarios? Yeah. Building off of what Aaron said, I think there are several advantages to the suture lock. The first thing is that it's reliable. The fixation is excellent at the joint line, and we have the ability to retention to make sure we can get that meniscus perfectly anatomic and keep it there. The next thing that we notice is that the working distance or working length is significantly improved. We have fixation at the joint line. So that improves our biomechanics and our construct strength. So all of the things that we care about reliability, safety, improved biomechanics and anatomic repairs we get with the suture lock implant. Well, gentlemen, this evidence based approach really speaks to suture lock as a great option for our patients. Aaron, Justin, thank you for joining us today. Thank you. Thank you Chris. So to learn more about Suture Lock for meniscal repair, be sure to tune in to our other breakthrough episodes, including highlights on technique. Play by play. Making the Case. Lessons learned and the patient experience. Thank you for joining us.

Arthrex presents the SutureLoc™ Implant Series of the BreakThrough™ program. In this episode, leading surgeons walk through key steps and share pearls of the SutureLoc meniscal root repair technique. Joining host Christopher Adams, MD, are in-studio guests Aaron J. Krych, MD (Rochester, MN), and Walter R. Lowe, MD (Houston, TX).

 BreakThrough™ With Christopher Adams, MD—SutureLoc™ Implant Episode 2: Technique Play-by-Play

Welcome to breakthrough. On today's episode, we have Walt Lowe from Houston, Texas and Aaron Critch from Rochester, Minnesota to share their technique highlights when using the suture lock implant for meniscal root tears. Aaron and Walt take it away. Thanks, Chris. We're very excited to show you our play by play. Walt, can you set up the case for us? Yeah, the case has a lateral root repair that we're going to show you guys some of the tips and tricks that come along with using this new game changing device, the suture lock. And the first step is really to get that anatomy correct. Here we have this lateral root posterior footprint. How do you make sure you get that guide pin in the correct place. Well you know you've got to be able to see to work for sure. And so preparing that area to work is important. And so clearing all the soft tissue you can and then moving on into sort of getting that footprint of the root ready to compress the root route back down into it. Yeah, that biology is very important. And it also helps really pass that implant retrograde. You really don't want any soft tissue kind of hanging that up. Yeah I agree. And this video shows that really well to have an area exposed and have a have a foot plate ready to repair, I use a curette and then I use a power rasp to really get that ready to sink the route back down into it. Yeah. And then we're going to pass our 2.4 Cannulated guide pin here. Any pearls or tips? Sometimes that gets a little bit clogged with bone. Here we can really see that the tip of that central guide pin is up. What's worked in your hands. So there's a couple. First of all I pre-drill it with just a regular two four drill. Not all the way through to my guide, but just up to where you feel subchondral bone. So this piece is a little more flexible. Or this drill is a little more flexible. So it only has to pass that last few few millimeters when it goes in. So that keeps a lot of soft tissue problems from happening or bony hang up from happening. But you know, you need to see that sharp tip come through when you remove it distally. If you see water flow, then you're good. If you don't, then I run a little nitinol wire up it to clear that cannulated part of the drill, and then pass my lasso. Yeah, we saw that running water here, our nitinol wires coming up, and then it's really about passage of the implant, really shuttling that down. Retrograde. Any other tips or pearls? Yeah. You know, the wire can be kind of sharp and the bone can be kind of bad sometimes, especially in that typical medial route population that we deal with. So I switched the lasso out to a fiber link so that I'm having suture past the implant down the tunnel. And I think that makes me more comfortable. I'm going to keep my fixation point exactly where I want it. Yeah. And I'm just going to point out we really want all sheath in that shuttling loop to make sure that we don't prematurely tension that implant. Yeah. It's just every step of this is typically really smooth. But it's really important to be perfect at each one of them. So having that length and we'll show it here. The tibia as we're going in. Just giving yourself that length like you see on that loop right now to come out the distal tibia ensures you have all the pieces of this to make it work its magic. So we've passed it. Now it's really time to get organized, to really set that implant. What has worked well in your hands? Are you holding both ends of the sutures? Are you holding one? Well, for me, I have the suture coming out, the arthroscopic portal in one hand and the suture coming out distally on the other hand. So I constantly have a feel of the movement and the tension that's happening. And then you see that sort of little wrist roll that I just showed you there. That's a very nice way to sort of gently pull this down into that tunnel. And when you see the implant duck underneath, then you know you're ready to go to work. And that's when, you know, you say, how hard do you pull to set it? Pull pretty hard. You know, you'll get that gestalt that I can't pull this thing out even if I wanted to now. Yeah. And I've really found you'll feel that pop when it goes through. And then I just want to point out it's really important to grab all four of those sutures equally. We don't really want to shorten any of those converting strands before we're ready. Right. And you can wrap it around your finger. You can put a clamp on it or anything. But that's a really important part you make, because if you do that, you got to start over. Yeah. And then at that point we can really tension. And I'll even pull back those four strands a couple of times. Tension retention. The goal is really to get that right at the subchondral bone, because that's where our fixation happens with this implant. Yeah for sure. And and the feeling or the gestalt feeling of that is really clear when you do that. And then we'll take a clamp kind of on the tibial side. We'll clamp all the distal sutures coming out to again prevent that shortening of those converting strands. Then our next step is really suture management. And you have a couple great tips that I've learned from you. How do you manage your sutures during the case? Well, you got to keep them out of the way. You know, I think it's the first thing. So typically I'll sort of park them in the opposite portal. So if I'm doing a lateral route, I park them out the medial portal and vice versa. And the other thing is, I just want to do everything the same way every time. So I start with blue. I pass blue suture. I doc that suture down and then I'll move to white. So I know as I move through the procedure where I am and what I'm doing every time in an identical way. Yeah, I think that's really helpful. Just keeps the entire team engaged within the same steps for this suture management. And then once we have that repair stitch placed, then it's all about converting the suture. So at this point do you then grab these one at a time and convert them. I'll convert them as I go. And so I'll pass blue through the route. Convert it down but not tension it completely you know just leave it loose so you still have room to pass your white suture and convert it. And then they're both there waiting on you to sort of be totally focused on the tensioning of it. And then it's really important. I'll just emphasize that we use that pen mark. We really don't want to make sure that the suture is too short when we're shuttling it all the way and converting it through the tibia. Yeah, this is probably the most important step. I think if you sort of stratify them as you look at it, because this is what turns your suture, your blue or white, into the repair suture that sets its strength in that. So you want to come around that little blue mark on it. I actually go a little further, just so I'm not going to be nervous about it. And so as you see this go down the tunnel through the scope, I look down at my hand in the conversion suture, and I have my other hand underneath it, and I'm just waiting for that blue suture to land in my hand. And every time it does, you go, you know, we got it done now. Yes. We just unclamp it and then we do that conversion. It's super smooth. Very with this implant. Very. So then once we have kind of our tension out, you talked about that not final tension but a little bit of the slack out. Then at this point it just really becomes a repeat of the steps. Yeah it does. It's just, you know, blue conversion blue white conversion white. Focus on your route, put it in the position you want it and tension it down. Yeah I found this to be very efficient technique really reducing our surgical time? Yeah, definitely. So then once we have our two sutures placed, what do you do for tensioning, exactly? You know, I position the knee at about 90 degrees. I think that's where this is going to get tested there and further into flexion. And then I'll tension each suture as I'm watching the route, almost like I tension a tightrope, pulling a quad tendon graft up into the knee or whatever, sort of a little bit at a time, and watch it sit down and it can make you I want to pull a little more white. I want to pull a little more blue as you reduce it down into there, and then once it's there, then it's a pretty good hard tug on both of them at the end. Yeah. And then I'll just point out in this case we passed two simple sutures. But certainly there are other configurations available, especially if you have degenerative tissue. We can also do a mason Allen type of suture. Any other patterns that you've been able to play around with? Well, the use of this device is only limited by your imagination. Probably. And I think most of us, I think you'd feel the same way. We started with a simple suture through it, and then you go home. I can probably grab a little more than that. And you start flipping your scorpion upside down and passing horizontal mattress sutures through it. You know you can. There's any number of different suture configurations that help you deal with the tissue you're dealt. Yeah, I think the key is just getting that really significant compression at the repair site. Yeah. For sure. That was an excellent demonstration with insightful pearls. Aaron, for a brand new suture lock user, what's your key takeaway? Yeah, for me it's all about really deploying that. The lateral root the anatomy of the medial root I think is very important too. Thank you both again. Now to learn more about Suture lock for meniscal repair, be sure to tune in to our other breakthrough episodes, including highlights on innovative solutions. Making the Case. Lessons learned and the patient experience. Thank you for joining us.

Arthrex presents the SutureLoc™ Implant Series of the BreakThrough™ program. In this episode, leading surgeons discuss patient considerations when using the SutureLoc implant for meniscal root repair and highlight their clinical experience with two case presentations. Joining host Christopher Adams, MD, are in-studio guests Walter R. Lowe, MD (Houston, TX), and Patrick A. Smith, MD (Columbia, MO).&nbsp;

BreakThrough™ With Christopher Adams, MD—SutureLoc™ Implant Episode 3: Making the Case

Welcome to breakthrough. Today we'll be making the case for using the suture lock implant when repairing meniscal root tears with Pat Smith from Columbia, Missouri, and Walt Lowe from Houston, Texas. Gentlemen, thank you for joining us today. Thank you Chris. Thanks, Chris. Pat, what makes Suture Lock ideal for your repairs of the meniscal root? Well, Chris, this unique device has several major advantages. Number one, it allows us to get aperture fixation for the root repair for better stability. Number two, the implant has two sutures attached that have a knotless mechanism. So you can put different suture configurations within the meniscus. Well what do you like to do with sutures. What's your go to for those. You know it's anything everything Pat. I mean, we all kind of started off learning to do simple sutures in it and then have progressed to Mason Allen sutures, vertical mattress sutures, rip stops to help bad tissue. I mean, it's a really versatile device. How about you? What do you do? Yeah. You know, I was involved in a biomechanical study. We looked at that and we saw the mason. Allen was the strongest. So when I can do the Mason Allen, that's what I try to do most of the time. Yeah. That's cool. Walt, outside of your typical route repairs, does Sherlock have any other indications in your hands? You know, it really does. It's a really versatile device. And so, you know, it works great for repairs of l'amour, type one's l'amour, type twos, or the route equivalent type tears. And, you know, it's really progressed now to where I use it for the poster haunt of my medial meniscus transplants. I actually have a great case that'll demonstrate that to you guys. Please do. Well, this is the case I was telling you about, and she's a 41 year old female with about a three and a half year history of medial left knee pain. Her history sort of longitudinally, was she started with a repair of a radial type medial meniscus tear back in 2020 that came from jogging. That didn't do so well. She had a scoped partial medial meniscectomy because it didn't heal where we took out about half of her medial meniscus. And then you can see from there in 2023, a couple of years later, had this progressive, significant medial meniscus deficiency and now developing a huge chondral lesion on her medial femoral condyle. When you look at her exam, just exactly what you would expect from someone with these progressive medial compartment wear and a meniscal tearing. When you look at the MRI, you see the bony edema in the medial tibial plateau. You see the loss of cartilage on the medial femoral condyle. And at least on this cut a little smaller medial meniscus. The piece she was missing was more the mid body. So even though there was some meniscus left it wasn't functional. So the plan for her was to move on with a medial meniscus allograft transplant and a concomitant osteochondral allograft transplant of the medial femoral condyle. And the slide itself really shows this is just a beat up nonfunctional meniscus. So in this video, we've already passed the 2.4mm cannulated guide into the anatomic location. And you can see how anterior that is on the medial meniscus transplant. Following this we're now passing the suture loc. You see the suture that will come out the tibia distally going through. And then the sheets starting to come through here and now, slowly advancing the sheath down in and you'll see sort of the bulbous part come into view right here. And then that gets a little harder to pass. And you see it sort of pop underneath into the, the tunnel. And that's when we'll take the loop distally and sort of scrunch up this device into it and then set it where it's fixed, just underneath the subchondral bone. From there, it's all about tissue management. And I'm ready to pass the transplant now. So the sutures are out now through a little anteromedial portal, and sutures are being placed in the posterior horn, as well as a tiger wire, sort of in the mid body, to help reduce the medial meniscus transplant. Once that's done outside of the knee joint and the suture configuration, then we start to push and pull the meniscus in. And the suture is placed in sort of a horizontal mattress up through. And then flip the scorpion and down through. So this will pull this posterior horn down onto the footprint that we've prepared for it. You can see the tiger wire there. That's reducing it more immediately. But once the meniscus is reduced then you can see tensioning it with the suture lock and sitting it down in its anatomic bed that we had prepared for this transplant. From there, it really just becomes a sort of classic large medial meniscus repair like we'd do for any bucket handle tear of the medial meniscus. And I should note, once that poster horn was set, the anterior horn is set, and then the repair ensues. And that allows us to repair the capsule up to the meniscus, not the meniscus out to the capsule. So it'll help reduce extrusion. That was a great case with a unique use of the suture lock. Pat, have you utilized this technique in your transplants as well? Well, Chris, similar to what I've expanded my use of the suture lock to meniscal transplantation, one of the huge advantages is with the aperture fixation, we can actually do a concomitant tibial osteotomy and not worry about cutting through our fixation and losing our root fixation. I've got a nice case I'd like to show. That would be great. Thanks. Please do. So this is my case. This is a 40 year old male that was referred to me. Long history of problems with his left knee. Multiple surgeries starting in 1997 with a partial vasectomy. Then ended up having two medial meniscus repairs in 2022 and then 2023. Sent to me for ongoing knee pain to describe swelling pain at night limited with its everyday activities. Here was my exam. He had a mild joint effusion. His motion was good ligamentous the knee was stable but he was very tender on the medial joint line. Positive mcmurray's test and he had mild quadriceps atrophy. Here's his playing films. They look pretty good in terms of joint space. Here's his alignment film. You can see he's in Varus. Slight varus on this left side compared to the right. So that's obviously very important in this case. Here's his MRI. His lateral compartment looks good. Meniscus fine. Cartilage looks good. Acl is intact. You can see his medial compartment. Good news is the control surfaces look decent. Didn't see any big erosions. Any big osteochondral defects. Meniscus is pretty beat up on the sagittal. Same thing on the coronal view. Again. Important The lateral compartment looks good. If you're contemplating osteotomy, you need to make sure that's the case. Acl, PCL intact. And again you see the medial meniscus. A lot of abnormal signal. But the cartilage looks decent to me. So here's a diagnostic scope. The plan is for transplant and a tibial osteotomy concomitantly. You can see these sutures in the plateau. I'm not sure how this was a route repair because the route is untouched, but obviously pretty traumatized. Medial meniscus here. Cartilage is decent on the femur. Tibia is a little beat up. But again I'm going to do the concomitant osteotomy. So next steps. Looking at the rest of his joint here confirming his ACL is good. And then the lateral compartment. If you're going to do an unloading osteotomy you need to make sure the lateral side is in decent shape as it was here. Meniscus is good. Cartilage surfaces look pretty good. Some minimal counter calcinosis. Nothing too major. So here's the case. I take back the abnormal meniscus back to a good stable capsule rim. I like to leave about two millimeters of native meniscus to enhance the healing process for the native meniscus cells back into the transplant. Then I create my posterior anchoring point at the anatomic attachment for my suture lock. Here's my two four pin drill. My wire Now passing the suture lock, as we've shown. Right underneath the plateau. Set it and we've got our fixation. Also, though, I'm going to put a suture lock anteriorly. So here I bring my guide in another two four pin. Pass my wire. This is going to deliver my anterior suture lock for my anterior horn fixation. So you see the suture lock coming in anteriorly just as we showed posteriorly at the anatomic attachment here anteriorly. One real advantage of the suture lock is that I actually pass my sutures through the posterior horn outside the joint, and I converted about 80%. So I do a mason Allen configuration with the blue suture. Blue and white like a ripstop converted 80%. What that does for me, it helps me pass the meniscus into the joint. So I think this is a real another advantage of the suture lock. So you'll see here delivering the posterior horn c p for the posterior horn. And now remember I only converted 80%. Now I can convert it the rest of the way to get my fixation posteriorly. Now I use the scorpion to pass my anterior conversion sutures for my anterior suture lock. Then I used the one five fiber stitch to complete my repair. As you can see here, sutures on top and below the meniscus, and you can see the final transplant in position here with a nice fit. Then of course, I did the concomitant tibial osteotomy. The big advantage is with the suture lock implant. You only have to preserve two centimeters below the implant itself, and you're safe. So you don't have to worry about cutting sutures. So it's very easy to go ahead and do the eye balance here. Corrected this patient six degrees. Here's the post-operative x rays of the eye balance. And no problem doing the transplant first and then doing the tibial osteotomy again I'm trying to improve the quality of their life. And this implant with the transplant and the osteotomy together is a great combination. Hey Pat, that was a really good, good case for us all to see. You know, you've clearly been able to adapt the suture lock not only to the simple root repairs, but to these complex medial meniscus issues like transplantation. Is there anything you do special to augment the healing? Yeah. Well, it's a great question. You know, now because of the suture lock, we just have a small 2.4mm hole in the tibia. We don't have a socket anymore. So for healing purposes, what I've been doing is really abrading the footprint of the posterior detachment with the curette. Maybe even the poorest can work right there. Try to get some good blood flow to enhance the healing of the transplant in that location. Do you do anything different? You know, it's interesting. I started off, you know, from the old socket technique. And so I wanted to preserve bone. I wasn't quite comfortable going without bone. So I've started making a really thin wafer for the posterior part of the medial meniscal transplant, one that's so thin. I prepare a bed much like you do. I can still pass sutures through it in different suture configurations, through it using a scorpion, through a little bony piece at the at the posterior attachment. Yeah, that's a great idea, I like it. Well, gentlemen, thanks for sharing your experiences and making the case for suture lock. To learn more about suture lock for meniscal repair, be sure to tune in to our other breakthrough episodes, including highlights on innovative solutions, technique, play by play, lessons learned, and the patient experience. Thank you for joining us.

Arthrex presents the SutureLoc™ Implant Series of the BreakThrough™ program. In this episode, leading surgeons share their experiences and the educational tips and pearls they learned while incorporating the SutureLoc implant for meniscal root repair into their practices. Joining host Christopher Adams, MD, are in-studio guests Justin J. Mitchell, MD (La Crosse, WI), and Patrick A. Smith, MD (Columbia, MO).

BreakThrough™ With Christopher Adams, MD—SutureLoc™ Implant Episode 4: Lessons Learned

Welcome to breakthrough. Today we're going to be discussing the use of the suture lock implant for meniscal root avulsions with Pat Smith from Columbia, Missouri, and Justin Mitchell from La Crosse, Wisconsin. Gentlemen, thank you for joining us. Thanks, Chris. Thanks, Chris. Pat, as one of the first users, you have a lot of experience with Suture Lock. What's something you've discovered that may help surgeons speed through the learning curve? Well, Chris, I think the key is how to set the implant. If you can't, I have a model that please do show. Justin, can you hold this for me? Yeah. Of course. So this is our model, and we have our cortical bone here in beige and our cancellous bone in pink. So once you pass the suture lock beneath the tibial plateau, the first thing you want to do is forcefully pull on the four sutures representing your passive suture through the meniscus. Once you pull forcefully there, then you pass your finger through the black and white loop and you set the other end, which balls it up to the implant underneath the plateau. But it's important to do the proper technique of setting the top four sutures first and then the black loop below, and you're done. That's a great tip, Pat. Justin, as you know, suture lock is double loaded, which increases the number of constructs we can create. Any tips on managing the sutures? I think there's a few things we really need to pay attention to. The first thing is we want to have an accessory portal of some type, whether that be anteromedial or anterolateral, just opposite of the side of the meniscus that we're fixing. I typically use a passport. Passing those sutures through the passport really helps make sure we're not getting entangled and allowing us to pass our sutures appropriately. The second thing is the sutures are color coded so you can start with the suture color every single time. So you can make sure you're doing the repairs in exactly the same manner each time. Then the final thing is the implant as it comes out of the tibia. We want to put a clamp around that. That makes sure we don't unload the implant and make sure we pass our sutures safely. Justin, the other thing I would add to that though, I like the fact that we can in the configuration, I tighten the blue suture typically first from my horizontal mattress, about 85% of the way. Then I passed my other searcher, which is the white suture over the top for the rip stop and then sequentially tighten them as you watch it. So I think that ability don't tension on both at the same time, go back and forth with with the two sutures and I think you'll get your strongest fixation. Totally agree with that, Pat. How have you and your patients benefited from being able to retension the implant during fixation, something that we previously didn't have? Well, because, you know, our standard Transtibial technique, once you set your implant distally, you're done. You're almost afraid to go back and look at your repair for fear it's going to change position. Right. But now we can retension it. So I think that's really the key for me. A couple of things are important. We take the knee out of valgus because frequently we've done a pie crusting or a superficial MCL lengthening procedure. I tend to put the knee at about 50 degrees neutral position. I set it by my tension, my final two pull on both of the sutures of the tibia. Then I'll cycle the knee to 90, look at it and retention of that position. But I think that really gives us the strongest possible construct. So Pat, those are great points. And you talked about being able to retention And what angle do you set the knee in when you retention it? I'm just curious, do you think this has actually helped out keep your meniscus repair is more anatomic? Yeah, I think it has been. I think you have to be careful. You want to be in the anatomic position with your with your marking root guide. First of all. Second of all, Justin, I make a point to really abrade the tibia a bit right where I'm going to put the meniscus back for healing, because remember, we only have that small two four hole. We don't have the socket before. So I think that's another technique to enhance the healing at the anatomic root. Those are all great pearls. Now can you both leave us with some final thoughts in regards to lessons learned while using the suture lock? Yeah, Chris, you know, I've been really impressed with the limited pain that patients have as compared to my previous techniques. We're drilling a small 2.4mm hole, as you said, and I think that really does reduce pain. Now it's an all suture implant. We're not using harder implants like buttons on the anterior tibia. And that anterior tibial pain that people used to have seems to have completely gone away. So people are pushing me harder to do more rehab earlier, be more aggressive with their activity sooner than I would have expected with this implant. Yeah. Chris, for me, I think it's the exciting possibility that we can start earlier. Weight bearing. You know, traditional care for root repair patients is strict non weight bearing for six weeks. Part of that was our fixation wasn't great. Right now we've shown the suture lock is stronger biomechanically in the lab. I'm hopeful that we can now show earlier weight bearing in our patient population. Because to me it's going to open up a whole group of patients. We can help because right now I see patients like you do Justin, in the clinic that I know can't be non-weight bearing for six weeks. But if we can show that you can early weight bearing, these root repairs hold up because of the suture lock strength, we're going to open up a good operation to many more patients to help more patients in the long run. Gentlemen, thank you both for your insight. Now to learn more about the suture lock for meniscal repair, be sure to tune in to our other breakthrough episodes, including highlights on innovative solutions, technique, play by Play, making the case, and the patient experience. Thank you for joining us.

Arthrex presents the SutureLoc™ Implant Series of the BreakThrough™ program. In this episode, leading surgeons share how their patients have benefited from the SutureLoc implant for treating meniscal root tears. Joining host Christopher Adams, MD, are in-studio guests Aaron J. Krych, MD (Rochester, MN); Walter R. Lowe, MD (Houston, TX); Justin J. Mitchell, MD (La Crosse, WI); and Patrick A. Smith, MD (Columbia, MO).&nbsp;

BreakThrough™ With Christopher Adams, MD - SutureLoc™ Implant Episode 5: The Patient Experience

Welcome to breakthrough. On today's episode, our panel of experts will be discussing how the suture lock, implant and technique for meniscus repair has positively affected their ability to treat their patients. Joining us in this roundtable format are Pat Smith, Erin Krich, Walt Lowe, and Justin Mitchell. Gentlemen, take it away. Thanks, Chris. Gentlemen, we all have been a group of early adopters of the suture lock technique. I know I've seen some improvements in my ability to treat these patients. Justin, what about you? Yeah, Pat, it's impressive how little pain these patients have early on and how they're able to weight. Bear a little bit sooner than I would even like them in some points. I've had several patients who have sort of pushed our protocols even beyond what I would hope. I have one patient who has a very high BMI, a weight upwards of £400, who was not able to follow our postoperative protocols for family and work reasons and started weight bearing much earlier, complained of no pain, was able to Ambulate normally was able to do squats and bends by three months, and now he's greater than six months out and has maintained essentially no pain. Normal ambulation has gotten back to work, so this shows me that these people are feeling better sooner, and that this implant has been able to hold up and withstand the rigors of daily life, even in our most complicated and less ideal patients. So, Justin, did you change his protocol? No, I think he changed the protocol for me. Yeah, but it is interesting that this kind of gave me the idea that maybe we could change the protocol. I'm curious. Erin, what do you think about that? Yeah, I think we're at an interesting time where we can start asking those questions. Clearly, we know from the biomechanical data that it is a stronger sort of construct than our old transtibial route repairs. So I think maybe in full extension, probably allowing some weight bearing would be reasonable. I think we still have to avoid that past 90 degrees of flexion though, with that femoral rollback. What do you guys think. Yeah I mean for me kind of the same thing you think? I'm not comfortable going past 90 for a month. Probably until we have some healing, you know? And I think it's a very efficient system that have made our times a little quicker and more predictable. And the other thing, it's done from everything I said, I sleep better at night after I use this than any other way I've ever fixed a route. Yeah, well, it's interesting because anytime you're making a technique change or a product change, you wonder, is it going to change your or times? Is it going to make things more difficult for you? And of course there's some technique variability. But as you use this now our times are back down below 20 minutes for these cases. Well I think the other thing comes into play with the weight bearing is the ability to retension it. Right. So in the operating room, you just feel a whole lot better with the suture lock that it's tight to think about that earlier weight bearing. And again our patients experience has been more comfortable. So Justin I think we're on to something with this. Pat building off of that. What's your favorite takeaway from previous techniques that you've used when comparing to this one? You know, I think it's easier quite honestly. The suture management, you know, having residents and fellows, it's really easy to show them how to use the knotless technology, which we know from our shoulder cases, and we've transformed it into meniscus root repair. I think that's a big advantage for this particular device. And again, the aperture fixation. But that ability to retention, I think comes back to me every time. Do you think we've solved the question in terms of what angle of flexion we're tensioning this construct at? Well, you know, it's something I struggle a little bit about. You know, I typically fix it about 5050 degrees of flexion or so. But I always take it to 90 degrees and then I do my tensioning. But you know, maybe it's better to do it. What's your preference in terms of what angle do you strive for in the operating room? Yeah, I think I'm a little bit higher in flexion probably that 70 to 90 degrees. I've just felt that that tension. Is it a little bit better. It gives a more secure construct. But I think the other thing to consider though is remember we are in valgus. A lot of times we're doing a, you know, pie crusting technique where we've lengthened the superficial medial ligament. So I always try to reduce it when I'm when I'm doing my tension. I think that's another key point. When you're, when you're doing that final tension reduce valgus that might be created by our exposure. Well, I'm more worried about the materials than I am the laterals, for sure. In that tensioning part of it there. And the other thing I think we need to make a habit of is when it's all said and done, when we're done with the case to take the knee through a full range of motion, put the scope in and look at it one more time, I think is going to be a good habit to develop. Yeah, there's nothing worse than when you get done with your case going back there and feeling like you don't have the fixation that you want. And I think that point is crucial. And this implant allows you to do that retention and make sure you have it right where you want it. Exactly. Well, gentlemen, it's been great hearing your positive patient and practice experience. Thank you all. To learn more about the suture lock for meniscal repair, be sure to tune in to our other breakthrough episodes, including highlights on innovative Solutions, technique, Play by Play, Making the case, and lessons Learned. Thank you for joining us.

Arthrex presents the SutureLoc™ Implant Series of the BreakThrough program. This collection features all five of the BreakThrough episodes detailing case presentations, surgical demonstrations, scientific literature review, and panel discussions highlighting the SutureLoc implant. Joining host Christopher Adams, MD, are in-studio guests Aaron J. Krych, MD (Rochester, MN); Walter R. Lowe, MD (Houston, TX); Justin J. Mitchell, MD (La Crosse, WI); and Patrick A. Smith, MD (Columbia, MO).