O reparo do manguito rotador sem nós oferece aos cirurgiões a capacidade de poupar tempo e elimina a possibilidade de dor contínua no ombro devido ao impacto do nó. A Arthrex oferece muitas opções de âncoras sem nós e técnicas cirúrgicas que fornecem reparos robustos com resistência de fixação comparável às técnicas tradicionais com nós. O relatório APT - Arthrex, Inc. LA0219A. Naples, Flórida; 2008
Certas âncoras e parafusos biológicos (PLLA e PLDLA) não estão disponíveis para venda na região EMEA.

Shoulder

Procedure

Continuando a evolução no reparo do manguito rotador sem nós, a técnica FiberTak SpeedBridge™ é completada com âncoras de tecido mole 2.6 FiberTak RC na fileira medial e suturas FiberTape® fixadas lateralmente com âncoras SwiveLock®.
Este reparo sem nós cria uma construção rápida e segura em apenas três etapas de passagem de sutura. O tamanho pequeno das âncoras 2.6 FiberTak RC permite três pontos de fixação na fileira medial onde anteriormente apenas dois pontos de fixação podiam ser alcançados.
As âncoras sem nós 2.6 FiberTak RC são adaptáveis e podem estar em conformidade com as técnicas tradicionais de reparo, ao mesmo tempo em que fornecem os benefícios adicionais da tecnologia tensionável sem nós para incorporar produtos biológicos ou aumentar a compressão da fileira mediana.

This animation demonstrates the features and benefits of the Knotless FiberTak® SpeedBridge™ implant system.

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FiberTak® SpeedBridge™ Implant System Features and Benefits

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FiberTak® SpeedBridge™ Rotator Cuff Repair

The FiberTak® SpeedBridge™ technique is completed with 2.6 FiberTak RC soft anchors on the medial row and FiberTape® sutures fixated laterally with trusted SwiveLock® anchors. This knotless repair creates a quick, secure construct in as few as three suture-passing steps. The small size of the 2.6 FiberTak RC anchors allows for more points of fixation in the rotator cuff footprint. Knotless 2.6 FiberTak RC anchors are versatile and can conform to traditional repair techniques while providing the additional benefits of tensionable knotless technology for incorporating biologics or increasing medial- row compression.

The FiberTak SpeedBridge is a knotless double row rotator cuff repair technique that provides improved footprint, contact, and compression compared to traditional techniques. This procedure is completed with 2.6 FiberTak RC soft anchors on the medial row and secured laterally with self-punching SwiveLock anchors. Using a mallet, insert and advance the 2.6 FiberTak RC anchor into bone. If preferred, a guide can be used to aid in anchor insertion. Stop at the insertion zone. Laser line if hard bone is encountered. Use a punch or drill through a guide to create a socket to aid in anchor insertion. Once the anchor is fully inserted, remove the inserter. Grasp all limbs of the sutures and pull slightly to set the anchor. Repeat these steps for anchor insertion for the middle and posterior anchors. These anchors are preloaded with a SutureTape that can be incorporated into the repair or removed if not needed. Any bone preparation, such as a PowerPick or Bur should take place lateral to anchor insertion site for the medial row. Using a mini KingFisher retriever from the lateral portal. Retrieve the FiberTape from the posterior anchor. Load the joined FiberTape tail from this anchor into a Scorpion suture. Passer and pass the tail of the of the FiberTape through the rotator cuff, passing both FiberTape limbs at once. Once passed through the cuff, retrieve the FiberTape from the percutaneous portal used for anchor insertion. Repeat these steps to pass the other sets of FiberTape with the Scorpion suture. Passer. Cut the joined FiberTape tails and retrieve one FiberTape limb from each medial row. Anchor through the lateral portal. Load the FiberTape tails through the eyelet of the self-punching SwiveLock anchor and achieved the desired position on the lateral row. The eyelet can be steered to find the optimal site for anchor insertion. Once this location is determined individually, tension each FiberTape limb and insert the self-punching SwiveLock mallet the Self-punching SwiveLock by starting with light taps to initiate insertion. Then proceed with normal taps until the anchor is in contact with the bone. Hold the thumb pad and rotate the driver handle to advance the anchor until it is flush with the bone. Remove the SutureTape tip retention suture from the SwiveLock anchor. Cut the FiberTape suture tails. Repeat these steps for the second lateral row anchor. This completes the FiberTak SpeedBridge, which offers improved footprint to bone contact versus traditional techniques.

Patrick J. Denard, MD (Medford, OR), demonstrates how to use 2.6 FiberTak® RC anchors and 4.75 mm SwiveLock® anchors to complete a knotless double-row FiberTak SpeedBridge rotator cuff repair.

Today I'm going to demonstrate a rotator cuff repair using the FiberTak SpeedBridge construct. Laterally we're going to use the Knotless SwiveLock anchors our workhorse anchor. Medially we're going to demonstrate the Self-punching two six FiberTak RC anchors. These anchors have a fixed FiberTape with joined tails to simplify suture passing. This is a self-punching version that can be placed with or without a guide. You can utilize the laser marks adjacent to the bone for placement without a guide or laser marks more proximally. When it is placed with a guide, this self-punching aspect is very nice because it simplifies the steps for rotator cuff repair. So here we have a right shoulder. This is a large rotator cuff tear. In my mind, this is a tear that's amenable to a three anchor medial row repair. And I like the FiberTak RC anchor because this allows us to place three anchors with minimal violation of the footprint. So we can maximize footprint contact area without violating the bone as much as compared to hard body anchors. Here's our anterior anchor placed adjacent to the articular margin through an ASL portal. Next we're going to place a middle anchor. We're going to use a self-punching aspect to this to save steps. You can see the depth is marked on the inserter to confirm appropriate depth of placement. We can also set the anchor by gently pulling the tapes to bring the sheath up against the bone. Finally, we're going to place our posterior anchor through a percutaneous portal. In this case, we will use a guide. A spinal needle is used to determine the adequate angle of approach. We make a stab incision to help introduce the guide. And now we're going to reference the marks closest to the handle to confirm adequate depth of insertion. At this point we have all three middle row anchors placed. And we have the option of incorporating the suture tapes within each anchor sheath. But in this case we're going to go with an entirely knotless construct. So we remove the suture tapes leaving us with three sets of fiber tapes, one from each anchor anterior, middle and posterior. And you can see these are color coordinated to really help distinguish them in the joint. Next we're going to pass these sutures through the rotator cuff. So we retrieve a FiberTape out the lateral cannula. This FiberTape has joined tails so that it can be loaded onto the Scorpion and allow a single pass of both limbs simultaneously through the rotator cuff tissue. I like to pass from posterior to anterior once the suture is passed, we want to retrieve this out. The same portal used for anchor placement. We'll then move to the middle anchor and pass the sutures in the same manner. Finally, we retrieve the FiberTape from the anterior anchor and pass those through the anterior aspect of the supraspinatus tendon. Now we have all three sets of FiberTape pass through the tissue anterior, middle, and posterior. Next, we need to cut the ends of the FiberTape to separate the two FiberTape limbs. We retrieve one of the limbs from the anterior anchor out the ASL portal. The other limb is left out the lateral portal. We then need to retrieve one limb from the middle and the posterior anchor. We're first going to place our posterolateral anchor. We'll insert the punch to the laser line. The sutures are loaded through the eyelet of the swivel lock, and while hovering the eyelid above the socket, we will remove all slack from the construct. We will then insert the anchor. We use a FiberTape cutter to cut the sutures adjacent to the anchor. Now we're going to retrieve all the remaining limbs out the lateral cannula and place the anterolateral anchor. We punch to create our socket. Again, all three tapes are passed through the eyelet of the knotless SwiveLock, and with the eyelet above the socket, remove the slack from the fiber tapes. Once the slack is removed, we insert the anterolateral anchor. So here are our Knotless construct is completed, but we're going to assess the anterior cable. We want to reinforce that anterior cable, which is really important. Biomechanically. So we're going to cut those FiberTape limbs. And with this Knotless SwiveLock, we're going to retrieve the repair stitch and pass this through the anterior cable outside the shoulder. We're going to load the repair suture into the loop, and shuttle the loop through the body of the anchor to engage the knotless mechanism within the SwiveLock anchor. You see, this is going to nicely reduce the anterior cable. And while tensioning this I like to use an instrument such as a post cutter to provide a counter force to the bone or anchor as we tension the knotless mechanism. Here's our final repair. Viewed through a posterior portal, you can see we have three medial anchors taken out the two lateral anchors and a knotless construct. This construct allows us to get broad compression across the footprint, which is nice for a large tear such as this rotator cuff tear. Thank you.

This animation demonstrates the use of the FiberTak® SpeedBridge™ implant system to independently repair the layers of a delaminated tear using tensionable Knotless FiberTak RC suture anchors.

Delaminated Rotator Cuff Repair Surgical Technique Animation

When treating rotator cuff tears, it's important to first assess the tear pattern of the rotator cuff to understand how the tendon will reduce to the footprint. In some cases, you'll find a delaminated cuff tear in which the layers of the rotator cuff will reduce to the footprint at different points. In cases like this, a dual layer FiberTak SpeedBridge construct is used to address the layers of the tear. With the first 2.6 FiberTak RC set in bone, retrieve the repair suture from the anterior anchor through the lateral portal. Load the repair suture into the Scorpion suture passer and pass the repair suture through the inferior aspect of the delamination. Retrieve the loop end of the shuttle suture from the lateral portal. Load the repair suture into the loop, folding at the purple mark. Convert the knotless mechanism by pulling the SutureTape end of the shuttle suture from the percutaneous portal. Next, pull the repair suture to tension the inferior aspect of the delamination, but do not fully reduce the loop tension. Each repair suture individually to fully reduce the inferior aspect of the delamination. Repeat these steps for the posterior and middle anchor. Once proper tension is applied, cut the tails of the repair sutures. Retrieve the anterior FiberTape. Load the joined tails into the Scorpion suture. Passer and pass the FiberTape through the cuff. Repeat this step for the other two FiberTape sutures. Once all the tapes are passed, cut the joined tail of the FiberTape sutures. Retrieve one limb of FiberTape from each anchor and use the Mega Loader to load them into the Self-punching. Knotless. Swivelock. Anchor with the eyelet above bone. Remove slack from each limb of FiberTape with all slack removed. Press the Self-punching SwiveLock anchor to bone and maintain forward pressure. Use a mallet to tap lightly to advance the eyelet through the cortex. Mallet until the anchor body is touching bone. Once the anchor is touching bone, advance the SwiveLock anchor in place. The lateral knotless mechanism can be used for cable reinforcement. This completes the FiberTak SpeedBridge construct, allowing for differentiated tension of the layers of the delaminated tear.

A list of scientific articles pertaining to a product or procedure.

Eine Liste wissenschaftlicher Artikel zu einem Produkt oder Verfahren.

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Lista de artigos científicos referentes a um produto ou procedimento.

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All-Suture Anchors for RCR

Knotless Double-Row Rotator Cuff Repair Scientific Update

Reparo do manguito rotador com FiberTak® SpeedBridge™

BioComposite SwiveLock SP, 4.75 mm x 24.5 mm, self-punching titanium eyelet, qty. 5

Fadenanker, Bio-Composite SwiveLock SP, 4.75 x 24.5 mm, self-punching,perforiert, VE5, steril, IM

Suture Anchor, Bio-Composite SwiveLock SP, 4.75 x 24.5 mm, Self-Punching, Vented

Anclaje de sutura, SwiveLock SP de BioComposite, Ø 4.75 mmx 24.5 mm, au

Âncora de sutura, Bio-Composite SwiveLock SP, 4.75 mm x 24.5 mm, autoperfurante, perfurada

Âncora de sutura, Bio-Composite SwiveLoc

BioComposite SwiveLock SP, 5.5 mm x 24.5 mm, self-punching titanium eyelet, qty. 5

Fadenanker, Bio-Composite SwiveLock SP, 5.5 x 24.5 mm, self-punching, perforiert, VE5, steril, IM

Suture Anchor, Bio-Composite SwiveLock SP, 5.5 x 24.5 mm, self-punching, Vented

Anclaje de sutura, SwiveLock SP de BioComposite, Ø 5.5 mm x24.5 mm, aut

Âncora de sutura, Bio-Composite SwiveLock SP, 5.5 mm x 24.5 mm, autoperfurante, perfurada

PEEK SwiveLock SP, 4.75 mm x 24.5 mm, self-punching titanium eyelet, qty. 5

PEEK SwiveLock SP Fadenanker, mit Metallspitze (Ti), perforiert, 4.75 x24.5 mm, VE5, steril, IM

Suture Anchor, PEEK-SwiveLock SP Self Punching, 4.75 x 24.5 mm

Anclaje de sutura, SwiveLock SP de PEEK, autoperforante, Ø4.75 mm x 24.

ANCORA DE SUTURA EM PEEK SWIVELOCK SP, AUTO-PERFURACAO, EYELET DE TITANIO E FIBERWIRE #2 (4.75MM X 24.5MM)

PEEK SwiveLock SP Fadenanker, mit Metallspitze (Ti), perforiert, 5.5 x24.5 mm, VE5, steril, IM

Suture Anchor, PEEK SwiveLock SP, 5.5 x 24.5 mm, Self Punching, Vented

Anclaje de sutura, SwiveLock SP de PEEK, Ø 5.5 mm x 24.5mm, autoperfora

ANCORA DE SUTURA EM PEEK SWIVELOCK SP, AUTO-PERFURACAO, EYELET DE TITANIO E FIBERWIRE #2 (5.5MM X 24.5MM)

SwiveLock SP, Titanium, 4.75 mm x 24.5 mm, self-punching titanium eyelet, qty. 5

SwiveLock SP Fadenanker, mit Metallspitze (Ti), perforiert, 4.75 mm x 24.5 mm, VE5, steril, IM

Suture Anchor, SwiveLock SP, 4.75 mm x 24.5 mm Self Punching, Vented

Anclaje de sutura, SwiveLock SP, Ø 4.75 mm x 24.5 mm,autoperforante, fe

ANCORA DE SUTURA SWIVELOCK SP, AUTO-PERFURACAO, C/ FIBERWIRE #2, EYELETPONTA DE METAL (4.75 MM X 24.5 MM)

Child (D)

A técnica de fileira dupla SpeedBridge é usada para reparar rupturas do manguito rotador usando uma âncora SwiveLock® totalmente roscada, combinada com sutura FiberTape® para criar uma construção rápida e segura sem nós e apenas duas etapas de passagem de sutura. A técnica de fileira dupla SpeedBridge usa sutura FiberTape que triplica a área de contato em comparação com uma sutura padrão #2 FiberWire®. Ela fornece um footprint amplo que pode ser útil em reparos de degeneração de tecido do manguito, em que a movimentação possa ser uma preocupação.
Referência
1. Arthrex, Inc. LA0239A. Naples, FL; 2008.
Algumas âncoras e parafusos bio (PLLA) não estão disponíveis para venda na região EMEA.

Paul C. Brady, MD (Knoxville, TN), uses the new Knotless SwiveLock® anchors to complete a SpeedBridge™ rotator cuff repair. Dr. Brady demonstrates how to reduce and fixate the cuff with a knotless double-pulley, which is followed by the SpeedBridge repair with knotless dog-ear fixation.

SpeedBridge™ Repair With Knotless Medial Pulley

Hi, my name is Doctor Paul Brady from Knoxville. And today I'm going to show you a SpeedBridge technique with a knotless medial double pulley using these new Knotless SwiveLock anchors. So here we have a left shoulder. We've created a a anterior supraspinatus tear. I've prepared the bone bed with the cautery. We'll place our anterior anchor while I'm visualizing intra-articular. So let's find a good angle to come in. So I think that's going to be a good angle to insert my anteriormost anchor. I'm going to have my assistant just gently externally rotate the arm. So I'll make a nick in the skin. I'll use my punch to create my bone hole. And we'll put this right at the articular margin of the humeral head. Go ahead and insert that the SL. I like to bury the second line and just barely see the SL mark. And then we'll put our first anchor in here. So we'll insert that anchor into our bone socket. Good. And then we'll go ahead and insert that anchor. So we have that down. Now we'll unwind just a little bit to make sure that anchor is flush with the bone. Just turn our paddle in one direction. Now we see that anchor is well seated flush with the bone. So we can go ahead and remove that. We'll take the tab off and then we'll pull that anchor straight out. Good. And that's our anterior anchor. Now we'll go subacromial and we'll pass these sutures. First I'll pass the FiberTape sutures. I'll bring my FiberTape out my lateral portal. The FiberTape are swaged into a single FiberWire suture. I'll then load that into my Scorpion. And I'm going to pass these FiberTape sutures at my most anterior aspect of my tear. That way my double pulley is going to going to be medial or on the inside of my FiberTape sutures. So we'll get a good grasp of the tissue. Make sure my reduction is appropriate. And we'll pass that. Utilizing a Scorpion suture passer. We'll take all the slack out of that. And then I'll pull that out. An alternate portal. We'll take it out. The same portal that I inserted the anchor. Now we're going to bring our repair suture and the shuttle suture out my lateral portal. And we're going to shuttle those just posterior to where we just passed our FiberTape. So we'll get all those sutures in our FiberTape retriever. And then we'll load onto a Scorpion. We'll load the end of the FiberLink. And we'll use this FiberLink to shuttle. If you hold tension on these sutures. Holding tension helps it so that you don't Cross your sutures with your FiberTape. We'll go just a few millimeters posterior to where we pass the fiber tapes, and then we'll pass our shuttle suture. The reason I like to pass these as two separate passes is it prevents any potential tangle or potential twisting between my repair suture and my FiberTape sutures. Sometimes, if you get an inadvertent twist, it makes it hard for the FiberTape to fully seat and compress the medial cuff. So by doing this as two separate steps, it prevents that potential twisting that can occur. So that's that's the passage of my first anchor and my first set of sutures. Now you can see the passes of the FiberTape sutures anteriorly. And just behind that is the repair suture, which is blue, and the shuttle, which is black and white. Frequently I find it easiest to insert the second anchor while visualizing from my lateral portal. And again, I'll place this right at the articular margin of the humeral head. Right to the cell level. And then I'll insert my second knotless SwiveLock anchor preloaded with a blue FiberTape. I always put blue in the back. We'll compress that down until the anchor is right on the bone. Get a nice squeak here. Maybe a half turn. There you go. Now let's back it up to look and make sure we're seated. It looks like we are just like the first anchor. I'll first take my FiberTape sutures. An easy way to differentiate is I'll push all of them away from me, and Ryan will pull my FiberTape toward me. There we go. It's a little trick to make it easier. We'll load that onto the Scorpion hold tension. You can see Ryan's holding the tension on the FiberTape. That's another little trick that really helps it not to twist or tangle. We'll push these out of the of the way, and then we'll grab underneath our cuff and let's try a little bit of internal rotation. We'll grab a posterior bite here. All right. Now to get those FiberTape out of the way we'll we'll bring them back up through our anchor insertion site. We'll pull those FiberTape out of the way. And now we'll take the repair suture and the shuttle sutures. And. We'll place these sutures just anterior to the FiberTape that we just passed. Close, but just anterior. We'll pull that suture up through our anchor insertion site. We'll shuttle those sutures through our tissue, pull out the slack on our fiber tapes. Now we're going to complete our medial bridge. We'll take our posterior repair suture. Again, here's the trick. We'll take all these sutures. We'll push them all away. And I'll pull on the repair suture, which is white. We'll pull that out our lateral portal. Another way to differentiate your shuttle suture from the loop is push them all away, and you can tell that the loop is round. The shuttle suture is flat. Okay, so you want to pull your round limb out your lateral portal. And that's going to be the looped end of your shuttle. You're going to load the repair suture into the loop of the shuttle right up until the blue mark. And you're going to double it over right at the blue mark. Now we'll pull on the shuttle suture. When you meet resistance, you give it a little tug, tug, tug until your repair suture is coming out. Now we're just going to load that repair suture. I want to tension it very gently so that So that it's just sitting on top of the tissue, but it's not compressing the tissue. It's good to leave the first loop a little loose, so that it allows you to complete the second splice without difficulty. So we'll take the anterior repair suture out our lateral portal, and we'll take our shuttle suture which is the round suture. We'll load the repair suture into the loop of the shuttle and double it over right at the blue mark. We'll pull on the shuttle suture. It's best to pull the shuttle suture from the same direction that you inserted the anchor. That's why I pulled the shuttle suture out my anchor insertion portal until that's in the cannula. And then once you get some tension, give it a little tug. Tug, and then we'll pull it down until it's just loosely on the tissue right about there. So now I have two loose limbs on the tissue. So obviously you don't have to go back Intra-articular, but I think it makes a good demonstration to watch this double pulley do its trick. So Ryan's going to take alternating anterior posterior limbs pull tension and you can see that create a nice compression of the superior capsule down against the articular margin of our bone bed. Really reestablishes the medial footprint very nicely. So we'll look at this from the lateral portal as well. Again we have our repair suture posteriorly, repair suture anteriorly and a bridge of compression between the two. You can see that that's compressing medially nicely. We can cut those sutures at this point. I find that a nice technique is to use the small closed cutter. We can put that small closed cutter right on the, on the tissue. I can even compress a little more, get a last a little bit of compression and pull tension. We'll repeat that process with the anterior suture, so that medial bridge has served several functions. Number one, it's compressed the medial tissue down against the prepared bone bed that reestablishes the articular margin of your supraspinatus repair, which is your superior capsular reconstruction. And it also tensions the rest of the rotator cuff so that the rotator cuff sits in a perfect position, allowing you to simply bring alternating FiberTape limbs laterally, compress them into two lateral SwiveLock anchors for the completion of the SpeedBridge portion of the repair. We'll cut the wedges between our fiber tapes, both the blue ones and the white ones. I'll take a FiberTape retriever at this point and simply complete our SpeedBridge. [00:10:03] Let's just squish down that little tail a little. All right, let's tap that. And your anchor is ready to go. So these new knotless swivel locks have a groove in the eyelet here, and it helps to align those suture tapes so that they don't crisscross each other when you insert them into the bone. So I keep the eyelet just outside the hole, and I do some gentle tensioning of both my blue and my white suture. And then I compress that into the bone. Go ahead and tap until the anchor is right up against the bone, and then we'll go ahead and advance that. Until it's flush with the bone. That looks great. Pull the tab. Now, these lateral anchors are also knotless SwiveLock anchors. And they can be very helpful for reducing a dog ear if you should have one. So we'll hold tension on those islet and shuttle sutures, and we'll place our FiberTape cutter on the FiberTape sutures. So we want to make sure that only the FiberTape sutures are in the cutter. I keep the blade of the cutter away from my eyelet suture, and then I'll pull tension on my FiberTape limbs, cut those flush with the bone, and that leaves our repair suture as well as our shuttle suture, in case we need to use that for a dog ear. We'll just bring all those limbs out an alternate portal for right now. We may or may may not use them. And we'll complete the SpeedBridge by taking the other limbs of the FiberTape. We'll take the other blue limb and the other white limb. I'll take my colored punch. I'll put that right on the bone. There. Tap that. Great. I'll pull it back, but I won't pull it out. I'll load my FiberTape sutures into my lateral SwiveLock. Anchor I'll get this right above my hole. And I'll do some gentle tensioning. And then I'll compress it into my bone tunnel. Good. And we'll make sure we're all the way down. That looks good. Now we can pull the tab and pull our anchor out. And again, I'll keep those those sutures separate. We'll pull tension on the fiber tapes. Cut that flush. And now we can use this repair suture for a dog ear. Should we have one? So here's our repair. We have that medial bridge of compression. You can barely see it. It's so well compressed. We have our fiber tapes crisscrossing, coming laterally into our two lateral SwiveLock. And we still have these repair sutures laterally that we could use for any residual dog ear. Should we have one. So let's show you a technique of using that lateral suture for dog ear reduction. There's a small dog ear. Posteriorly, we might be able to get that suture through there to reduce that small dog ear. So I'm going to take from my lateral portal. I'm going to just take the repair suture which is the all blue suture. I'm going to pull that out my lateral portal. We'll load that into a Scorpion. So there wasn't much room posteriorly. So I'm going to use the lateral Scorpion to get underneath that dog ear and get a little bit better bite of my posterior dog ear. Once the repair suture is passed through, I'm going to take both limbs of the shuttle suture out my lateral cannula. Since I inserted the anchor through this lateral cannula, I'll do my shuttling from the lateral cannula. I'll bring both limbs of the shuttle suture out laterally. I'll pass the repair suture through the shuttle to the To the mark, and then I'll take the flat limb and pull that into my anchor. Little tug. I'll pull that down until it's just snug. At this point, I like to take the closed cutter, load the end of the suture through the closed cutter, and I'm going to use this closed cutter as both a tensioner and a cutter. I'm going to put it right on the anchor. It fits right on the anchor. And if you watch that suture right there, now I can tension that and then tension a little bit more. And then when I'm ready I'll just cut it flush. So that added a small dog ear reduction to our SpeedBridge rotator cuff repair. This anterior anchor I don't think I can fit it underneath anything anteriorly. I think we've got a good reduction. So I'm just going to go ahead and pull the shuttle suture out. So this suture we can't we can't pull this out because it's fixed into the eyelet of the anchor. So we have to cut it. So we'll put that cutter right on the bone and cut it. So we didn't use the knotless mechanism from our anterior anchor, but we used the knotless repair suture from the posterior anchor to get our dog ear. And let's look at it from lateral. We have a nice SpeedBridge repair along with a posterior dog ear suture. For posterior reduction. We have a medial bridge of compression that is hard to even see because it's so well compressed. And I always like to take a final view from Intra-articular. And so our final intra-articular view looks truly anatomic. It's stable with internal external rotation abduction. So hopefully those tips are helpful utilizing the new Knotless SwiveLock anchors.

James P. Bradley, MD (Pittsburgh, PA), uses the new Knotless SwiveLock® anchors to complete a Compression SpeedBridge™ rotator cuff repair. Dr. Bradley demonstrates how to add additional compression to a Knotless SpeedBridge repair using a knotless double-pulley from the medial anchors.

Compression SpeedBridge™ Rotator Cuff Repair

Good morning. I'm Jim Bradley from the University of Pittsburgh Medical Center. We're going to talk about rotator cuff repair and this new concept called the compression SpeedBridge. We have a patient with left shoulder pain. And he's 64 year old right hand dominant male weightlifter for many years with several years of shoulder pain. He acutely worsened this over six weeks. His resting pain 5 or 6 out of ten increases the ten out of ten with any kind of weightlifting activity, and his pain increases with lifting overhead activity specifically and cross-body motions when he's getting dressed, his range of motion, he's got 120 degrees of overhead forward flexion. He's got 80 of external rotation and he's got internal rotation to the iliac crest. His abduction is 120. His strength is four out of five. Supraspinatus and infraspinatus and subscapularis. He's got positive O'Brien's Hawkins empty can maneuvers and he's tender over his bicipital groove. The imaging is really not that impressive. We thought we had a rotator cuff tear. It's there, but we didn't think it was that significant? However, we're going to talk about what we did do. This new technique called the compression SpeedBridge here actually is the tear when we get in there. It's kind of a T shaped tear. It's it's across the greater tuberosity. And then there's a split into the supraspinatus. So the first thing we're going to do is we're going to repair the t part of it so that we can make it now a big U. So we repair in the top part which is right there, we use a Scorpion pass it four times two different fiber wires. One's going to be a white TigerWire and the other is going to be a blue one. So we don't get them mixed up. Once we tie this arthroscopically and get it back to, as you can see, a U. Now we're going to do the compression SpeedBridge. So this is the most important thing in the construct. We use knotless swivel locks. We use a blue, a blue FiberTape one in the front and a TigerWire white one in the back. With the locking construct, it's important to get right at the level of the humeral head where the beginning of the footprint is. Another trick is to see how I'm lifting it up. Lifting up with my probe. So if you can't see exactly where you want to go through your center portal, you just lift it up so you can see exactly where to set those down. And you can see I'm right on the edge of the cartilage. And that's very important. The construct then looks like this again, like we spoke before. You have to make individual passes of each one. So number one you're going to take all the mechanism and one of the fiber tapes out the front. And I use collagen coated fiber tapes by the way all the time. Then you're going to take number two individually with the Scorpion and make that a little more medial in the construct. And take number three, which is just a fiber tape. And we're going to make that more medially. And then we're finally going to take all four with a FiberLink out the back. So you have four separate passes one and four have the entire mechanism, and one FiberTape two and three just have an individual FiberTape at the junction of the muscle tendon junction and the rotator cuff. It looks like this when you do it. And obviously we're using a to pass the the front and the back we used to have we have to use an unloaded FiberLink to pull everything through. After this is complete this is the finished repair. You can see one and four are shorter than two and three. And once again, the most important thing in my mind are the cables. So an anterior and the posterior cable I use links with to make sure that we have the anterior and posterior cable down. Arthroscopically. It looks like this. Passing. It's meticulous. You got to be very sure that your twos and threes are more medial. So here it is again. I'm tensioning them. I tension all three of them. And then what I'll do is I'll put it in the final construct looks like this where you have anterior posterior cable repair, you have independent passes of all the fiber tapes. And then you have the knotless mechanism over the top pushing the medial compression on the rotator cuff repair. The final construct looks like this. And then we're going to use the anterior loop suture. And we're just going to tension it down. Now the important thing at the end of this is you want to use a knot pusher to really push it down and get some compression. And the final construct, you're going to be very satisfied. You simply cut it and then you rotate the arm through range of motion. And it's been it's been very advantageous in my hands, especially for people with poor tissue. But I'm using this on almost everybody but poor tissue. It seems to grab the cuff and set it down much, much better. Thank you very much.

Katherine Burns, MD (Bridgeton, MO), reviews literature supporting double-row rotator cuff repair and the SpeedBridge™ technique, along with surgical pearls for improved footprint coverage and outcomes.

Cowboy Way Advanced Shoulder Arthroscopy: Double-Row Repair—Why and How?

Good morning. I'm going to talk to you about double row repair. Why and how? Okay. So what are the goals for rotator cuff repair? Well, we have a lot of goals for rotator cuff repair. But truthfully, no matter what the tear looks like, whether it's a simple tear or this more complex, delaminated degenerative tear that you see here, we have the same goals. We have mechanical goals. We want to have good mechanical strength of the construct. We want to restore the footprint. We want to get adequate contact pressure of the tendon to bone. As you heard about this morning, more and more we have biologic goals. So we want to optimize the healing environment, whether it's using vented anchors or adding PRP or bone marrow. And then if you work in a surgery center, if you have a busy practice, you have utility goals. You want the technique to be quick and efficient. You want your text to know what they're doing and make it easy for them. You want one system that's going to work for all kinds of tear patterns, and ideally the system should be cost effective. So I want to tell you why this is my go to. The SpeedBridge is really the gold standard. It's a workhorse for rotator cuff repair. It's adaptable. It's expandable. You can use it for all different kinds of tear patterns. It provides really secure initial fixation. It you also have multiple anchor options for really hard bone. You can tap the bone. For really soft bone you can use a smaller punch or a larger anchor. Metal tips for Self-punching are available. It's still a ways down the road, but they're working on Self-punching peak tips. Now we know we have FiberTak anchors that we can utilize as well as Knotless SwiveLock, so it's really changing the game. We have that same system, but we're able to continue to improve upon how we're able to get fixation. The literature really shows that the biomechanical evidence favors a SutureBridge or osseous technique over a single row or a double row. We know that this technique provides higher failure loads, greater contact pressure, but it is important to note that so far we really don't have clinical differences between these techniques. The important thing to thing to realize is that even the level one studies are pretty underpowered, so they may be prone to type two error. We also know we have the option of not adverse is not list SutureBridge. So we have the option of tying medial knots. And it is true that the biomechanical studies show that medial knots and now with the knotless, potentially the medial pulleys or medial compression will increase the stiffness of the construct, increase the ultimate load to failure and GAP formation in cadaveric models. However, there is some concern that making this construct too stiff may be what's contributing to type two Retear the Retear at the Musculotendinous junction. And as we all know, that can be a really difficult problem to manage. Doctor Park also looked at the biomechanics of a knotted versus knotless SutureBridge technique, and interestingly, the knots actually had an adverse biomechanical effect by inhibiting self reinforcement. So what is the self reinforcement? Self reinforcement in SutureBridge is basically a mechanism by which the tensile forces on the tendon translate to compressive forces at the footprint, and it's thought to do this by changing the shape of the sutures from more rectangular to trapezoidal, decreasing that alpha angle that you see there, and basically wedging the tendon against the bone, increasing frictional resistance, and increasing resistance to failure of the construct. So another study done by Smith in 2017 showed that whether you tie knots or not, whether you secure down that medial row, increasing tension on the repair does increase the footprint contact pressure for both groups. But the self reinforcement was enhanced in the knotless group, and there was no difference between these two techniques in yield load stiffness ultimate failure. So while the cadaveric studies can be helpful, it's always really important to think about how this is going to work in an actual patient. So Doctor Millett looked at 151 patients and compared a technique in which he had used knotless tape bridge technique to a knotted SutureBridge technique. And again, no clinical differences can be found between these techniques. They both had good clinical outcomes, good Outcomes, good functional outcomes. But in his study, the Knotless tape. Technique was less likely to have a full thickness rotator cuff tear on MRI. At follow up. So this is why I use the SpeedBridge. It really is a workhorse. It provides excellent initial fixation for me. It's very efficient in the O.R.. It comes in kits. Now, the kits are packaged with the needle. My texts know what to expect. Everything is there for them. It's reproducible. It's flexible and adaptable. From small to very large. Tears. I get good clinical outcomes, so currently I prefer the SpeedBridge with a knotless tape technique. And I will augment with collagen or with biologics as I see fit depending on the patient. So how do I do a SpeedBridge? This is a 65 year old woman with a really large rotator cuff tear, but as you can see, the articular surfaces look pretty good. So she did want to avoid reverse. This is a pretty large tear. So typically what I'll do is medial eyes off the articular margin. I like to use traction stitches to help pull the rotator cuff over. Typically when I do this, I will incorporate the biceps into my anteromedial anchor. You can see that I like to use the the FiberLink to pull the the tissue over. And that's going to help me realize that this patient actually needs an expanded SpeedBridge. So in this case, I'm actually going to place three meteoro anchors and three lateral anchors due to the size of the tear. I can use those traction stitches to help place my permanent stitches. And then as I get those permanent stitches into place, I can start to see how that cuff is going to mobilize over to the tuberosity. And it looks like there will be enough cuff to get coverage. Another great thing about the SpeedBridge that you heard is that you have different options with anchors. So here I'm actually using a smaller punch. And then as you see it go down, this will be a larger anchor than the standard SpeedBridge with the blue handle. And I'll do that because of the bone quality. Another nice tip is that if you throw in those FiberLink traction sutures, you can incorporate them into the lateral row. It's just more fixation. It's easy. It really adds no extra time. And then here on this posterolateral anchor, I'm just demonstrating the technique by which you tension attention each suture individually, so that you can be sure you get great initial footprint, contact pressure, and a great initial footprint area. So putting that last anchor in, you can see that I really I did no special slides or techniques. And you can see I got full coverage of this humeral head with reasonable tissue across the entire footprint area, starting out with what really looked like a bald eagle situation. So just the basic SpeedBridge works great for me. It really is a gold standard in my hands. There's a lot of variation, so we're starting to hear about them now. It's always exciting to look at new things. And so here this footprint you can see it's a much smaller area of footprint exposed. So in this case I used the 2.6mm FiberTaks. They just make a much smaller hole. I even had room to put a third one if I wanted. Once those are past you can just incorporate them into the lateral row, just like you would with your standard SpeedBridge. With regard to dog ears, I like the FiberLink. So here you can see the stitches are in place, but I've got some anterior tissue that isn't fully secured. So if I just throw a FiberLink in and then pull it over to the lateral row, you can use that for a dog ear. And that's actually before I put the second anchor down in the lateral row. And you can see I already have great compression that's even across the footprint. And that's before I even finish the repair. You're hearing a lot today about the knotless techniques. There are so many options. You can use it for a medial pulley, a medial ripstop. You can use those knotless anchors to secure your dog ears. So the knotless SpeedBridge is going to give us even more opportunities for fixation using the same construct that we already use and that we're already all very familiar with. So I highly recommend that you play around with that. A few technical pearls and a lot of these. You've heard from my colleagues as well. I like for portals. So I put two portals kind of on the 25 yard line laterally. I like to use the 70 degree scope as it kind of gives me a bird's eye view. I do use a tissue grasper to plan and assess, but as you saw from my videos, I'm really liberal with use of the FiberLink for traction sutures. Suturetak. They really are easy to throw in and then allow you to put traction and you can incorporate them into the repair. I generally work from anterior to posterior. For me, I like to save time by not shuttling the stitches a lot, so I keep them all in the same portal. But as you can see, I have to have my assistant holding tension on those stitches, pulling them toward the elbow. So whether you do beach chair or lateral, keep them down toward the elbow and then just bring your Scorpion up over and work above the stitches. I do it the same way every time, working from anterior to posterior. Usually the tears are going to be retracted posterior immediately and so I'll be pulling them anterolaterally. I did want to briefly mention the SOS system. You know, if your institution or organization allows you to participate, this is a HIPAA compliant way that you can enroll your patients and get patient reported outcome measures. So you can use this on a tablet or a phone. It's really easy for you and your patients to use, and it will give you some leverage because you get these patient reported outcome measures and can track your patients over time and compare how your patients do overall compared to national or global data. I would mention that patient reported outcome measures are coming. It really looks like we are going to need to be providing this information before we can get approval for procedures. I really believe that's on the horizon. So it might be important to think about how you're going to incorporate that into your practice. And this is an easy, painless way to do it. That really requires very little effort on the part of you or your staff. So looking at the SpeedBridge, again, when we look at them versus single row repair, even with the SOS data. Patient reported outcome measures track pretty evenly at about two years, but we're starting to see some divergence over time. This is for the visual analog scale for pain. We see the same thing with the same score starting to diverge over time. So another nice thing about the SOS system is it really may be a powerful tool for us to understand how these patients are going to do long term, because we want our patients to be doing well, not just one year or two year, but hopefully five and ten years still with intact repairs. Thank you.

Lee Kaplan, MD (Miami, FL), demonstrates a SpeedBridge™ rotator cuff repair using Knotless SwiveLock® suture anchors to create a medial mattress ripstop repair configuration. A tensionable knotless mechanism is built into the anchor eyelet to easily create the medial mattress ripstop stitches. Dr. Kaplan also demonstrates how it can be used for lateral rotator cuff cable reconstruction.

SpeedBridge™ Rotator Cuff Repair With Medial Ripstop Sutures and Knotless SwiveLock® Anchor

This is a right shoulder. It has a large rotator cuff tear. We're going to use a double row technique. We'll start with the Anteromedial SwiveLock. We're using a separate punch hole to go through. And here's the punch being added for a medial row. I'm creating a bone socket for the SwiveLock through the punch. I'm now inserting the Knotless SwiveLock anchor that includes the preloaded FiberTape loop. And we'll remove the driver and you can see the FiberTape limbs and the knotless tension mechanism. Sutures. Now we'll pass the FiberTape. I'll use the FiberTape KingFisher to retrieve them laterally. We'll then load them in the Scorpion and I'll pass the tapes medially. You want to go to the junction as medial as you can safely within good rotator cuff tissue. We'll pull that out and remove it laterally. We'll then bring the FiberTape through a separate portal to allow us clearance to pass the ripstop sutures. We're separating out those separate tails and then placing our separate ripstop mechanism. I've now removed the blue suture shuttle, and we're going to pass those stitches through, pulling them through. I'll now pass a FiberLink. And that will allow me to shuttle the suture limbs at the same time. There are three sutures on this mechanism. And you want to grab the shuttle suture limbs. We're now passing the FiberLink, and I do that lateral to where the tapes are. So I really develop a rip stop mechanism. We'll then pass those shuttle sutures, and once passed, we'll park them. I'm then going to grab the repair suture, which I'll pass posterior to my shuttle sutures utilizing the Scorpion. Now, I'll retrieve my repair stitch and the looped end of the shuttle suture. And I'm passing the locking mechanism stitch into the shuttle suture. We're then passing that stitch, and you can see the medial compression. We're not pushing it all the way down to leave room for our posterior anchor. Now we'll place our posterior medial SwiveLock. I'm now creating the bone socket utilizing the punch. We're pulling our tapes out, utilizing the KingFisher, getting ready to load that into the Scorpion and passing the We park the tapes in a in a safe, clear passport. And now we're ready to repeat our locking mechanism technique. We're taking the shuttle SutureTak, retrieving them and passing a FiberLink. Once again, a bit lateral and posterior to my tapes. I'm then retrieving my repair stitch and passing my repair stitch through the tissue. Now I'll grab the repair stitch and the looped end of the shuttle. The looped end of the shuttle is round and the pull strand is flatter, so you can differentiate those articulately. We're going to load the repair stitch through the loop and pull it through the mechanism, locking down the medial row. I'm now inserting the knot pusher through the portal where I inserted the SwiveLock. Once I have the tension on the posterior medial, I'm cutting it and now I can move to my anterior suture. I'm once again going in line, tensioning it and cutting it. I'm now separating the tapes, and I'm taking one anterior and one posterior tape for my lateral row anchor. I'm using the punch to place my lateral row anchor. I'm cutting the tapes believing the locking mechanism sutures. And you can see that there's still a remnant of the anterior cable. Some people call this a dog ear, but I think this is an anterior cable reconstruction. We then pass the locking stitch. And you can see how it brings down that anterior cable Into its appropriate position. Here I'm using a knot pusher, which I like to help tension. We've now placed the posterior anchor, and now we still have the posterior cable or a dog ear, and I'm passing the repair stitch directly through. Using a Scorpion, I put it through the repair loop and bring it down, and I can tension that entire posterior cable. As you can see, adding the medial sutures in a ripstop technique increases. The coverage of the footprint, increases the amount of tendon security against the bone, and we added the anterior and posterior cable reconstruction. I feel that using this technique gives me the most secure reconstruction of this type of rotator cuff repair.

Ilya Voloshin, MD (Rochester, NY), presents a case study on a 72-year-old female patient with an acute-on-chronic massive rotator cuff tear, which was treated using the arthroscopic expansion SpeedBridge™ repair. Dr. Voloshin discusses using the SwiveLock® anchor and FiberTape® suture to achieve restoration of the rotator cuff footprint, help prevent synovial fluid leakage, and help contain biologically active agents under the repair site.1
Reference:
1. Aydin N, Karaismailoglu B, Gurcan M, Ozsahin MK. Arthroscopic double-row rotator cuff repair: a comprehensive review of the literature. SICOT J. 2018;4:57. doi:10.1051/sicotj/2018048

Expansion SpeedBridge™ Repair for Massive Rotator Cuff Tear

I'm here to present the case of a 72 year old female with acute and chronic massive rotator cuff tear. So physical examination is really not significant except for the shoulder exam. She has a positive knee in Hawkins sign. She has limited active range of motion with forward flexion to 30 degrees, external rotation to 20 degrees, and internal rotation to L2, and that range of motion occurs with significant pain. Her passive range of motion is fairly good 170 degrees of forward elevation, external rotation to 80 degrees, and internal rotation to T10. She has a positive external rotation, lag sign and negative belly press, and her strength is two out of five. So she's basically pseudo paralytic on exam. So these are her x rays. Her scalp is intact and we can see a massive tear of the supraspinatus and infraspinatus with significant retraction. I want to point out that the humeral head is superiorly subluxed and not perfectly aligned in the glenohumeral joint. This is a sagittal T1 MRI showing significant fatty infiltration of the supraspinatus muscle. And we can see that there's definitely a chronic component to this injury that the patient has. My approach to this type of patient has been always to give it a shot with a repair, because I feel that if we can get at least some healing very often in this patient population, we'll be able to get them back to activities of daily living, and they're going to be happy. And our complications are significantly less for arthroscopic treatment as opposed to reverse. So let's look at our patient. We chose to proceed with the arthroscopic repair. Some of some of the basic principles is you want to assess the tension of the repair. Harrison McLaughlin outlined that one of the main principles is making sure that you have a tension free repair. So we decided to proceed with expansion bridge repair, where we going to have footprint restoration. And this is going to be a transverse equivalent type of repair. My preference is to put a statue of the most anterior portion of the rotator cuff to control the drug information and to provide the ceiling of the repair so that you limit synovial fluid extravasation, and then you pass your sutures through the tendon. So at this point we're tying our medial mattress stitches. These are the number two FiberWire suture limbs from each anchor. Now this is a little bit controversial. There's clinical evidence showing that you actually don't need to tie these stitches. And some people may argue this this may prevent the self reinforcing action of this type of repair on the rotator cuff, and diminishes the compression force that the tendon is seeing at the bone tendon interface. However, I do believe that this stitches play an important role in sealing the synovial fluid extravasation, which I believe is important for the rotator cuff healing. So at this point, we're doing our lateral row now, and we can see our final repair aligns the tendon very nicely over the tuberosity. And the repair is well sealed. Yield. So another important aspect of Expansion bridge is it allows you to have a containment of a biologic agent at the repair site. Some of the challenges that we have with the biologic agents is keeping them at the repair site to hopefully improve the healing. So what I usually use is a bmac and we harvest the bone marrow from the proximal tibia. Once the cocktail is obtained and the repair is done, we can see on this video I put the spinal needle under the repair site. I inject the bmac cocktail. Once it's prepared at the repair site. And hopefully this sort of this type of construct allows containment of the agent at the repair site to improve the final healing. So just to summarize, the advantage of expansion bridge in this particular patient was restoration of the rotator cuff footprint. This type of repair I believe, minimizes the interface motion between the tendon and the greater tuberosity. And by minimizing that motion, it improves healing. It also prevents synovial fluid leakage and extravasation. So it improves the healing environment and also allows you to better contain the biologic agent at the repair site. So follow up on our case. At three months this lady had excellent active range of motion. We had reversal of pseudo paralysis. She had forward elevation at 170 degrees, external rotation to 80 degrees, and internal rotation to L5. She did not have external rotation lag sign anymore. Her strength was three out of five and she began strengthening at that point. At this point, at six months, she had forward elevation to 170 degrees. Her motion active range of motion was well maintained, but her strength improved and she was extremely happy. So my approach to this patient population, where not everything necessarily falls into a box and you don't have a cookie cutter approach, you have to analyze everything. You have to analyze patients age, size of the tear. But also the mechanism of injury, I think plays a very important role here. We had acute and chronic rotator cuff tear. And in this patient population, regardless of the age, I believe it's important to give them a chance, especially if they had a good function before, to see if repair will allow them to restore their emotion, control their pain, and allow them to get back to activities of daily living. And I believe in arthroscopic repair. It allows you to achieve that fairly consistently at a low complication rate. I always can send these patients for superior capsular reconstruction at the same time, so that if the rotator cuff is not repairable, we can proceed with SCR and allow them the arthroscopic solution to their problem. And then I think reverse is an excellent salvage procedure. You didn't burn any bridges. You can still go back and you can do a reverse and allow potentially a good salvage. But remember reverse comes at a cost. It's increased complication rate. It's a bigger surgery and it does not necessarily restore external rotation. So I believe it's important to give these people a chance with arthroscopic option. Thank you.

SpeedBridge™ Knotless Rotator Cuff Repair

Técnica em duas fileiras SpeedBridge™

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SwiveLock-Fadenanker, BioComposite, 5.5 mm x 22 mm, doppelt geladen mitFiberWire #2, VE5

BioComposite SwiveLock Suture Anchor,Double Loaded 5.5 x 22 mm, 5pcs

SwiveLock ancla con sutura, doble carga, BioComposite, 5,5 mm × 22 mm,

PEEK SwiveLock C Anchor, 5.5 mm x 19.1 mm, Qty. 5

PEEK SwiveLock Fadenanker, Closed Eyelet, 5.5 mm x 19.1 mm,VE5, steril,IM

Suture Anchor, PEEK SwiveLock C, 5.5 mm x 19.1 mm, Closed Eyelet

Anclaje de sutura, SwiveLock C de PEEK, Ø 5.5 mm x 19.1 mm,ojal cerrado

ANCORA DE SUTURA EM PEEK SWIVELOCK C, EYELET DE PEEK FECHADO E FIBERWIRE#2 (5.5MM X 19,1MM)

PEEK SwiveLock C, Double-Loaded, 5.5 mm x 22 mm, with two #2 TigerTail (White/Black and Blue/Black)

PEEK SwiveLock-Fadenanker, 5.5 mm x 22 mm, doppelt beladen mitFiberWire #2, VE5

PEEK SwiveLock Suture Anchor,Double Loaded 5.5 x 22 mm, 5pcs

SwiveLock ancla con sutura, doble carga, PEEK, 5,5 × 22 mm,5 unidades

A fixação rápida e segura em fileira única pode ser obtida com a técnica SpeedFix usando âncora SwiveLock® sem nós e sutura FiberTape®. O passador de sutura FastPass SCORPION-multifire é usado para passar uma sutura de colchoeiro invertida em uma única etapa. A sutura de colchoeiro pode então ser inserida na olhal da âncora SwiveLock® e implantada no orifício ósseo preparado, completando o reparo sem nós. O uso da sutura FiberTape proporciona 3 vezes a área de contato em comparação com uma sutura FiberWire® padrão nº 2.
Ele fornece uma área ampla que pode ser útil para reparos em tecidos degenerativos do manguito, onde a passagem do tecido pode ser uma preocupação.
Tenha em atenção que determinadas âncoras e parafusos bio (PLLA) não estão disponíveis para venda na região EMEA.

Reparo do manguito rotador sem nós

Reparo do manguito rotador com FiberTak® SpeedBridge™

Técnica em duas fileiras SpeedBridge™

Técnica em fileira única SpeedFix™