Name: SLAP Repair - eve
Uploaded: 2016-10-12T00:00:00Z
Channel: Arthrex

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VPT1-00704-EN | A | SLAP Repair

Jim Bradley

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SLAP Repair - eve

Let's start at the top. There's slaps. There's ten types of slaps. If you didn't know that, there are one through ten. Hopefully you know them. The classification system. But what are the causes of poor outcomes after slap repair? Well, first of all, it's poor patient selection and misdiagnosis, which is a lot. Failure to treat the coexisting pathology or failure to correct the predisposing mechanics or the patho anatomy. And then there's the technical pearls. So remember that the slap actually inserts on the side of the labrum. It doesn't start on the top. That's the bottom of the labrum. Just mechanics or just path of mechanics. Technical pitfalls. There's improper anchor placement. There's suboptimal absorption characteristics of the anchor that you choose. There's an over constraint of the biceps tendon. There's failure to provide favorable biologic healing. And then there's the persistent prominent malpositioned suture knots as you see in this picture. So John Connell and I talk about this good slap, bad slap. It's kind of a joke between us. But the slap there are actually good slaps. It's an adaptive process for overhead athletes and swimmers and tennis players. So a good slap is something that is purposeful. It's a beneficial adaptation, allowing greater labor, mobility, humor, elevation, external rotation, velocity, and performance. So a pitcher has an adaptive slap lesions most of the good ones. The problem is you can get a pathologic process or a bad slap, causing translational and rotational instability and micro motion at the extremes of motion of these athletes. And then you get a decreased performance and then you got a problem. So a good slap looks like this. They get pain relief when you inject them subacromial. It's a type one or type two slap that's chronic. It has good tissue and the slap kind of rolls back. It doesn't peel off, it just kind of rolls back. Your biceps is stable. It doesn't invaginate when you take the arm out and you move the arm, it doesn't invaginate. And then there's no rotator cuff tear. However, There's the bad slap now the bad slap. The pain is not relieved with a subacromial injection. So there's not secondary subacromial impingement. It's an anterior lesion, or it's a type 3 or 4 lesion. It's it's an acute event. There's a slap event where the patient throws and all of a sudden his arm just kind of falls to his side. That's called a slap event. The tissue is bad. The it's unstable with ever. So now it peels off. So when you take the arm out, you always got to take the arm out of your of your device and move it as you move it in external rotation. It will now just peel off instead of just roll back. And there's usually associated with a rotator cuff tear like you see on the bottom. What about a segment a superior segment. So there's a mobile superior segment. Is that a bad thing? Well, I would tell you, yes, I would say that it would. Preserving that make a difference in the answer to me is no because it's called edge loading. So if you know anything about neuroanatomy, you know there's free nerve endings in the labrum. And so what happens at edge loads the labrum and now you get pain. So what my suggestion to you is for that is you remove it like I show here in the slide. And then what you do is you use a knotless repair up top. And I'm going to tell you why. Because this is when I first saw this picture, Neal Elattrache sent this to me. And it's we all have it. We stole it from him. And this is a high level volleyball player, and you can see that that knot is going right and causing that rotator cuff tear. And that's when he said to me, I'm worried about these knots. And I said, well, after seeing this video, I surely am too. And that was about five years ago. So. So does rotator cuff cause humeral head abrasions. So do superior and posterior suture knots. Cause rotator cuff injury following slap repair. And should we still be tying knots above the equator? Not as not as important. Below the equator, but definitely above the equator. Should we be tying knots? So here's a study that was done in Jscs. And there's the the pre-op. Now look at the post-op. That's the rotator cuff right. That's and look at the rotator cuff tear. And look at the knots. See the knots stacks. They're not even covered. And now we have a rotator cuff tear. So I would say to you I'm going to propose to you that knotless labor repair with push locks. It eliminates suture abrasion on the control surfaces and synovium in the rotator cuff. It restores the anatomic position of the labrum on the glenoid, and the cannulated anchor now provides you an extra channel for marrow like we've seen before. So I'd prefer to do one of the two constructs to the right, rather than the one on the left, which I think you're going to get into trouble with. Okay, so. So you think we're good, right? We're pretty good, right? Well, not strength varies widely among surgeons. And it was the study was actually done here. This study was done here. And we had all these guys in here and everybody tied knots. So there's considerable variations in knot strength exist between arthroscopic knots tied by surgeons. So literally none of us can tie five consecutive knots of any type with any kind of consistency, whether you think you can or not, you can't. If you have ten years or less in practice, you're actually a better not tire than if you have ten years or more in practice. And if you have greater than 200 arthroscopic surgery cases annually, you fail to tie knots any better than the guy that had 100 or 50. So we think we're good, not tires, but none but none of us really are. So the other problem is the knots move. So you tie them on the lateral side on the one farthest away from the from the glenoid. But guess what. The knots move. So movement induced not migration was was fairly prominent if you look at this study in arthroscopy. So even though we think we're there we're really not there. And then the question is well if you do a suture versus a knot. So you see knotless versus knotted, are we any better. Well the papers that are coming out says we are definitely the same, if not better. So you're not losing anything if you compare one to the other. And so why did I change? So I changed, believe me, Bill Benowitz harped on me for like three years about going, you got to go knotless, you got to go Nautilus. Don't want to go Nautilus. I can tie knots. Well, finally, when I went Nautilus, I kind of never went back. And these are the reasons why I kind of changed the LabralTape I have. I can use short two nine push locks, which aren't as long. He mentioned the shorter drill. What you don't know is labrums are glenoid are different. So if you're off a tiny bit, you can go right out the back of the labrum or right out the back of the glenoid. So short drills in small holes is a much better way to go. The LabralTape versus FiberWire is 39% stronger. It has a 37% more pull out strength. And that's the failure mode. The failure mode isn't isn't that isn't the the anchor coming out of the bone. The failure mode is the the Gigli saw of the of the suture going through the labrum. So that's a 39% better. So beware of small glenoid. So my problem for these guys I said look these some of these small gymnasts have very small glenoid. And you say well you got to know what a normal glenoid is right. Do you know what a normal glenoid is. Well it should be 39mm top to bottom in an average. It's 29 across the bottom and it's 23 across. And that's Joe I am study of 140 different glenoid. So that's normal. But look look at the range. It went from 30 to 18 and 21. So it was 30 1821. Those are much smaller. So smaller glenoid beware of those because this is what happens. You get a smaller glenoid. You put your anchors are too big. You have too many anchors. And you get this thing called postage stamp fractures, which are really hard to deal with afterwards. So if you don't put big anchors in to begin with, now, you don't have as much of a problem. So then the solution was obviously to go to smaller anchors with LabralTape or some kind of SailTape. So why do I use now two four millimeter short PushLock and 1.3mm SutureTape for small glenoid? So I've gone to that. So the bigger ones I'll use two nines with LabralTape and then the smaller ones I moved to 2.4mm PushLock and SutureTape. Why do I do that? Because number one, there are polyblend. They've got some polyester in them. So the cells like them, there's no knots there. Pull out. Strengths are almost equal. In the recent study to the two nines. So I've got A24 with less suture, smaller hole, smaller drill. And now they're almost equal. Pull out. And if you compare SutureTape that's a single strand of tape. Not a cinch stitch a single strand. They're equal strength to a two to a number two FiberWire. But overall they have a 10 pound greater labral pull through strength than the FiberWire because of their construct, they kind of look like this. This is what I'm going to this, I think, is going to be the one in the future for me is a short two nine PushLock with SutureTape and a excuse me with SutureTape and a cinch stitch fashion. So this will be my construct. The cells like it because it's a poly blend, so the cells like to cover that up. So the Nautilus advantages I'm going to try to give you is it saves time, eliminates steps and there's no possibility of not impingement. You have pound and screw and you have you have also other options of screw in options. So if you don't like that, you can use a screw in option. It's bone preserving. It's an anchor design. It's very versatile. It's a you know, you can use a suture first technique or you can use the knotless SutureTak where it's it's an anchor first technique. You have multiple suture options. So if you don't like the one that I think you would be good. You have all these suture. You got FiberWire FiberStick FiberLink. You have LabralTape, you have SutureTape and then SailTape. So operatively you got to know your portals. Okay? This is how you how you get around. So you got to know these portals. If you don't know how to do these portals, the 5:00, 7:00 portal you got, you got to learn percutaneously. You can do them, but that's how you get the whole way around the labrum. So please, if you don't know that, ask the technical consultants in there. They will show you how to do that. Just a quick little case I don't have I don't want to go over, but I want to do want to show this. So here's a picture and they get these tubes slapped. Here's the Torpedo is a wonderful little instrument because it can get under the the labrum quite nicely. You want to elevate and you want to prepare that rim. The mistake people make is they spend too much. Oh there's the lesion. Let's fix it. No no no you got to prepare the rim to accept the sutures. And so you don't just spot weld it. You heal the whole thing down. It's really important. And I harp on it with my fellows all the time. I said, you got to take I'm not a very patient person, but now I'm patient for this. You got to be patient for certain parts. But this I'm patient with anyway. And I use this little minuscule rasp which works very well. Also, there's tissue resecting burrs that you can put in there and push it off or attracting birds, you can push it off. So after this, then what you want to do is I typically will use a real pass because of the angle. And it's a very small aperture. So I put my spinal needle in and I typically use this low profile cannula. I don't like the metal one as much. That's just my preference. But Arthrex makes this clear. Five millimeter low profile cannula that I can see through. And this is the real pass. It's the curvature is really good. The aperture is really small and it's really easy to work. I work all lateral decubitus. A lot of guys like posture, but it works for anything. It's got ten yards of suture in it, so you can use it for the whole case. And I simply shuttle through LabralTape. I'm not a big fan of grabbing a lot of the the gutter tissue. I think you're just asking for trouble and decreased range of motion, especially in throwers. So I stay away from that. So I'll pass these two initially. Stay out of the gutter Unless it's an offensive lineman, then I, then I grab as much as I can because those guys, you know, they like to hold. So if you if you limit their external rotation a little bit, they really like it because they don't get called for holding because their arms stuck like this. Oh, this is great, doc. This is great. I can that's how they call him, by the way. They get outside the plane. Once they get outside the plane, that's a whole. This is not a hold. You can grab as much as you want here, but once you get out of the plane, you're done. Anyway, I drill it and then you got to leave a little room for the labrum. So this is a short two nine PushLock. So you got to leave a little bit of room on it. Don't don't strangulate the thing for the labrum. All right? That's one of the keys. So you kind of say, how big is my labrum. And then you, you make sure it's, you know, and that the the cutter that he talked about, you want to spin the cutter. See I spin the cutter and I shove it in the hole that way none of the sutures above it. So we're going to move on here for time's sake. So the next thing is, if you want to go low, like a type eight slap or posterior, you can use this same system, this percutaneous system, they have the percutaneous system and use the same anchor. So it's a two anchor. It's a two cannula technique. That cannula down there is safe. I didn't believe it. I didn't believe the kerlan-jobe study. So I came to the lab and I dissected. And it's about 3mm or 3cm away from the axillary nerve in that position. I didn't believe that, but I believe me, that angle in the top left, that 35 degree, that's where you want to be. And that's kind of how you get to the low parts. I want to say one thing about slap extensions. I want you to know about this. In baseball players, there's a slap extension. It's called a type eight slap. And they'll split not only at the labral junction, but they split right through the labrum. And this is what I'm showing you. That's the split. If you don't fix both of those, you're not going to help them. So this is a third group Ben Kibler and I talked about in our instructional courses. So you initially get a tooby slap on the top and then it splits the labrum. Well why does it split the labrum is because there's a natural. Those are the two areas. There's a natural cleavage plane right there. This cleavage plane. It'll split here and it'll split there. You don't fix them both together. That picture is not going to that. That thrower is not going to get better. And you can do it easily with this LabralTape. So let's talk about outcomes with with this strategy that I'm giving you for anterior posterior superior. You should expect about 80% return to the same level after a slap without a rotator cuff repair. Rotator cuff repairs are a total different thing you can talk about together, but if you're going to do something that's traumatic, it's 90%. So if you have a traumatic anterior instability, posterior stability, it's about 90% return. If you look at the SOS system, which we do the SOS, if you look at Vas, sane Aces and simple shoulder tests, they're all somewhat better than the older techniques. So my suggestion to you is is do no harm and you want to think about going knotless. It's much more efficient. It's faster. You can do it for superior anterior posterior and really around the world.

SLAP Repair - eve

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