Patrick J. Denard, MD (Medford, OR), discusses his experience performing combined Bankart repair with remplissage for instability with bipolar bone loss using Knotless FiberTak® soft anchors.

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VID1-000686-en-US | B | Tensionable Knotless Bankart and Remplissage Using Knotless FiberTak® Soft Anchors

Patrick J. Denard

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Tensionable Knotless Bankart and Remplissage Using Knotless FiberTak® Soft Anchors

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The Bankart Rasp facilitates arthroscopic debridement of the glenoid rim in tighter joint spaces when inserted through an arthroscopic portal. The Bankart Rasp has a small 90° tip angle with a 4.65 mm x 7 mm surface and is well suited for preparing the glenoid rim in the anterior-superior quadrant.

Bankart Rasp

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The tensionable Knotless FiberTak soft anchor combines the benefits of soft anchors with knotless soft-tissue fixation. Curved and straight guide delivery systems are available with 1.8 mm drills, making this the smallest knotless anchor on the market.

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Remplissage for Anterior Instability Scientific Update Remplissage, which is used in combination with arthroscopic Bankart repair, addresses anterior instability associated with bone loss. Biomechanical studies indicate that insetting the posterior capsule and tendon into a Hill-Sachs defect improves joint stability. With recent innovations in knotless products and techniques, the addition of remplissage is more reproducible and efficient. A knotless technique—with two tensionable, knotless anchors and interconnected repair sutures—creates a reliably strong repair that minimizes the risk of knot impingement and migration. Clinical studies have consistently demonstrated that the addition of remplissage reduces recurrence rates, with minimal change to range of motion, compared to an isolated arthroscopic Bankart repair. When compared to Latarjet, remplissage appears to equally prevent recurrence but with a lower complication rate. Foundations Di Giacomo G, Itoi E, Burkhart SS Evolving concept of bipolar bone loss and the Hill-Sachs lesion: from “engaging/nonengaging” lesion to “on-track/off-track” lesion. Arthroscopy. 2014;30(1):90-98. doi:10.1016/j. arthro.2013.10.004 Reviews the impact of bipolar bone loss in anterior instability and treatment recommendations In abduction and external rotation, the contact zone of the humeral head with the glenoid—termed the glenoid track—is approximately 83% of the glenoid width Reduced both by glenoid bone loss and a Hill-Sachs lesion Calculate the width of the glenoid track with the following formula: 0.83D (normal glenoid diameter) − d (glenoid bone loss) Measure the width of the Hill-Sachs lesion to determine if the lesion is “on-track” (within the remaining glenoid track) or “off-track” (exceeds the remaining glenoid track) Authors recommend adding remplissage to off-track lesions with <25% glenoid bone loss Takeaways The normal glenohumeral joint has a glenoid track of 83% of the glenoid width in abduction and external rotation, which is reduced with glenoid bone loss or a Hill-Sachs lesion These concepts provide a paradigm of treatment for the average population but should be taken in the context of the individual patient (ie, an individual with laxity will have a reduced glenoid track due to increased likelihood of anterior subluxation while a low-demand, stiffer patient will have a lower likelihood) Shaha JS, Cook JB, Rowles DJ, Bottoni CR, Clinical validation of the glenoid track concept in anterior glenohumeral instability. J Bone Joint Surg Am. 2016;98(22):1918-1923. doi:10.2106/JBJS.15.01099 Retrospective study of 57 patients who underwent Bankart repair were evaluated at a mean follow-up of 48 months Hill-Sachs lesions were categorized as on-track or off-track based on MRI evaluation Recurrence was 8% in the on-track group compared to 75% in the off-track group (P = .0001) Shaha SH, Tokish JM Takeaway Patients with off-track Hill-Sachs lesions have a high risk of recurrence with isolated Bankart repair Biomechanical Studies Arciero RA, Parrino A, Bernhardson AS, et al The effect of a combined glenoid and Hill-Sachs defect on glenohumeral stability: a biomechanical cadaveric study using 3-dimensional modeling of 142 patients. Am J Sports Med. 2015;43(6):1422-1429. doi:10.1177/0363546515574677 Hill-Sachs lesions were created in 21 cadaveric shoulders based on modeling from CT scans in 142 patients with recurrent anterior instability Anterior translation was examined before and after Bankart repair in models with small and medium Hill-Sachs lesions with the following glenoid bone loss: Intact glenoid 2 mm bone loss (approximately 8% glenoid bone loss) 4 mm bone loss (approximately 15% glenoid bone loss) 6 mm bone loss (approximately 23% glenoid bone loss) Results showed that anterior translation persisted after isolated Bankart repair: With an 8% glenoid defect and a medium Hill-Sachs lesion With a 15% glenoid defect and a small Hill-Sachs lesion Takeaways Stability after bone loss is related to the combined effects of glenoid bone loss and the size of the Hill-Sachs lesion Isolated Bankart repairs may be compromised with as little as 2 mm to 4 mm of bone loss, or 8% to 15% of the glenoid width Hartzler RU, Bui CN, Jeong WK, et al Remplissage of an off-track Hill-Sachs lesion is necessary to restore biomechanical glenohumeral joint stability in a bipolar bone loss model. Arthroscopy. 2016;32(12):24662476. doi:10.1016/j.arthro.2016.04.030 8 cadaveric shoulders were placed in a custom apparatus to evaluate passive axial rotation followed by progressive translational loading A 15% glenoid bone loss model was used to evaluate on-track (15%) and off-track (30%) HillSachs lesions Repair conditions included isolated Bankart repair and Bankart combined with remplissage Results showed that engagement occurred: With 1 on-track lesion, which was prevented with isolated Bankart repair alone With all 8 off-track lesions, which was only prevented in mid-range rotation with isolated Bankart repair; prevention of engagement at end-range rotation was prevented in all specimens with the addition of remplissage Takeaways Funakoshi T, Hartzler R, Stewien E, Burkhart S Isolated Bankart alone results in persistent engagement of an off-track lesion in a bipolar bone loss model “Remplissage was necessary to prevent engagement of off-track bipolar lesions” Remplissage using interconnected knotless anchors: superior biomechanical properties to a knotted technique? Arthroscopy. 2018;34(11):2954-2959. doi:10.1016/j.arthro.2018.06.030 Cadaveric study of remplissage with 2 different techniques: Knotted technique with 2 anchors Knotless technique with sutures interconnected between the anchors (3.9 mm Knotless Corkscrew® anchors) Load to failure was higher with the knotless technique (788 N vs 488 N; P = .003) Most common mode of failure for the knotted technique was tendon tearing or knot failure No failures in the knotless group occurred via suture slippage Takeaways Constructs interconnecting knotless repair sutures between 2 anchors are superior to knotted techniques The knotless construct evaluated in this study can be reproduced with other anchors containing the same mechanism, including Knotless FiberTak® (1.8 mm or 2.6 mm) and 3.0 mm Knotless SutureTak® anchors Clinical Studies Garcia GH, Wu HH, Liu JN, Huffman GR, Outcomes of the remplissage procedure and its effects on return to sports: average 5-year follow-up. Am J Sports Med. 2016;44(5):1124-1130. doi:10.1177/0363546515626199 Retrospective review of 51 combined Bankart and remplissage repairs with large, off-track lesions and <20% glenoid bone loss Functional outcome and recurrence were reviewed at a mean of 5 years postoperative Six shoulders had dislocation events (11.8%) postoperatively Average loss of external rotation was 5° Rate of return to sport was 95.5% Kelly JD 4th Of those engaged in throwing, difficulty doing so was reported by 65.5% Takeaways Domos P, Ascione F, Wallace AL High return to sport with minimal loss in range of motion and low chance of recurrence with addition of remplissage Throwing difficulty is common after remplissage, but should be examined in the context that throwing difficulty is common in the setting of bipolar bone loss Arthroscopic Bankart repair with remplissage for non-engaging Hill-Sachs lesion in professional collision athletes. Shoulder Elbow. 2019;11(1):17-25. doi:10.1177/1758573217728414 Retrospective review of contact athletes with anterior instability and <20% glenoid bone loss evaluated at a mean follow-up of 26 months 20 athletes were treated with combined Bankart and remplissage Matched group was treated isolated Bankart There was no difference in postoperative range of motion Recurrence was 5% in the remplissage group compared to 30% in the isolated Bankart group (P = .015) Takeaway Recurrence in contact athletes is reduced with the addition of remplissage Haroun HK, Sobhy MH, Abdelrahman AA Arthroscopic Bankart repair with remplissage versus Latarjet procedure for management of engaging Hill-Sachs lesions with subcritical glenoid bone loss in traumatic anterior shoulder instability: a systematic review and meta-analysis. J Shoulder Elbow Surg. 2020;29(10):21632174. doi:10.1016/j.jse.2020.04.032 Systematic review of 379 patients (from 4 studies) who underwent combined Bankart with remplissage or Latarjet for <20% glenoid bone loss 194 Bankart and remplissage procedures 185 Latarjet procedures There was no difference in postoperative range of motion, functional outcome scores, or recurrence between remplissage and Latarjet groups (9.8% vs 7%) Risk of complication was 7 times higher in the Latarjet group (9% vs 1%; P = .003) Takeaway Hurley ET, Toale JP, Davey MS, et al Remplissage and Latarjet results in comparable rates of recurrence for subcritical bone loss, but complications are higher with Latarjet Remplissage for anterior shoulder instability with Hill-Sachs lesions: a systematic review and meta-analysis. J Shoulder Elbow Surg. 2020;29(12):2487-2494. doi:10.1016/j.jse.2020.06.021 Literature review of 12 clinical trials comparing arthroscopic Bankart repair and remplissage vs arthroscopic Bankart repair alone or the Latarjet procedure performed in patients with anterior shoulder instability with Hill-Sachs lesions Statistical results Remplissage plus Bankart repair had a significantly lower recurrence rate compared to Bankart alone (3.2% vs 16.8% P < .05) Complication rate was significantly lower for remplissage plus Bankart procedures compared to Latarjet procedures (0.5% vs 8.6% P = .003) No significant difference in revision rate of Bankart alone Compared to Latarjet procedures, no significant difference in recurrence rate, revision rate, or revision due to recurrence rate Takeaway Patients with subcritical glenoid bone loss have a lower risk for recurrance with remplissage with arthroscopic Bankart repair compared to Bankart repair alone. Latarjet has comparable rates of recurrence and revision but the risk of complications is significantly higher. Supporting Literature Shaha JS, Cook JB, Song DJ, et al. Redefining “critical” bone loss in shoulder instability: functional outcomes worsen with “subcritical” bone loss. Am J Sports Med. 2015;43(7):1719-1725. doi:10.1177/0363546515578250 arthrex.com © 2021 Arthrex, Inc. All rights reserved. DOC1-000498-en-US_A

Remplissage for Anterior Instability Scientific Update

All-Suture Anchors for RCR Scientific Update Rotator cuff repair evolved significantly as aspects of the procedure advanced over the years. With improved visualization, the procedure progressed from open to mini-open to arthroscopic, allowing fixation to evolve from large metal anchors to low-profile PEEK and biocomposite anchors to current soft anchors. Due to the size of soft anchors, more points of fixation can be achieved on the medial row while minimizing bone removal and maintaining construct strength and integrity. Several biomechanical and clinical studies have demonstrated the efficacy of these anchors in rotator cuff repair. Biomechanical Studies Bernardoni ED, Frank RM, Veera SS, Waterman BR, Griffin JW, Shewman EF, Cole BJ, Romeo AA, Verma NN Biomechanical analysis of medial-row all-suture suture anchor fixation for rotator cuff repair in a pair-matched cadaveric model. Arthroscopy. 2019;35:1370-1376. doi:10.1016/j. arthro.2019.01.023 Double-row RCR repairs were performed in 14 matched paired cadavers One group had 2.8 mm all-suture anchors medially One group had 5.5 mm hard-body anchors medially Both groups had 5.5 mm PEEK anchors laterally Mean load to failure was 618 N in the all-suture group compared to 545 N in the hard-body group (P = .339) Specimens with higher bone density trended toward higher load to failure with the hard- body anchors, but not with the all-suture anchors, suggesting that the hard body anchors were more impacted by bone quality Takeaways The biomechanical performance of a double-row RC repair with medial all-suture anchors is comparable to that of a double-row repair with hard-body anchors Demonstrates equivalent biomechanical performance of a double-row RC repair construct with an all-suture medial row compared to hard-body anchors. Ruder JA, Dickinson EY, Peindl RD, Habet NA, Fleischli JE Greater tuberosity decortication decreases load to failure of all-suture anchor constructs in rotator cuff repair. Arthroscopy. 2018;34(10):2777-2781. doi:10.1016/j.arthro.2018.05.030 Fixation of 2.9 mm anchors were evaluated in 10 matched paired cadavers Experimental group: 1.7 mm of decortication prior to anchor placement Control group: No treatment of the bone Mean anchor displacement was higher in the decorticated group No difference at 20 or 100 cycles 3.4 mm compared to 2.7 mm at 200 cycles (P = .05) Load-to-failure was lower in the decorticated group 314 N compared to 386 N (P = .049) Takeaway Decortication affects biomechanical properties of all-suture anchors and should therefore be minimized. However, the differences are small and overall, mechanics are favorable. Ntalos D, Huber G, Sellenschloh K, Briem D, Püschel K, Morlock MM, Frosch KH, Thiesen DM, Klatte TO Biomechanical analysis of conventional anchor revision after all-suture anchor pullout: a human cadaveric shoulder model. J Shoulder Elbow Surg. 2019;28(12):2433-2437. doi:10.1016/j.jse.2019.04.053 Cadaveric study of defects following pullout of 2.8 mm anchors Anchors were tested as follows: Placement of 2.8 mm all-suture anchor - Load to failure Placement of 5.5 mm hard-body anchor in the same defect - Load to failure Results compared to another group of 4.5 mm hard-body anchors There was no significant difference in load to failure between the 3 anchors Pullout of the all-suture anchors resulted in a mean defect of 4 mm Pullout of the 5.5 mm anchor placed in the all-suture anchor defect was not different than the 4.5 mm anchor Takeaways Load-to-failure of the all-suture anchor in this study was the same as that of larger hard- body anchors In the event of pullout of an all-suture anchor (ie, following intraop testing), fixation can be salvaged with a standard hard-body anchor without compromising ultimate fixation Clinical Studies Van der Bracht H, Van den Langenbergh T, Pouillon M, Verhasselt S, Verniers P, Stoffelen D Rotator cuff repair with all-suture anchors: a midterm magnetic resonance imaging evaluation of repair integrity and cyst formation. J Shoulder Elbow Surg. 2018;27(11):2006-2012. doi:10.1016/j.jse.2018.03.006 Prospective clinical evaluation of 20 rotator cuff repairs with soft anchors reviewed at a minimum of 1-year postoperatively Repairs were performed with a 2.9 mm all-suture based anchor, with an average of 2 anchors per case 95% of tears were healed postoperatively 10% of the anchor sites demonstrated fluid adjacent to the anchor No cases of cyst formation adjacent to the anchors were observed Takeaway All-suture anchors lead to high rates of healing without evidence of cyst formation following rotator cuff repair Dhinsa BS, Bhamra JS, Aramberri-Gutierrez M, Kochhar T Mid-Term clinical outcome following rotator cuff repair using all-suture anchors. J Clin Orthop Trauma. 2019;10(2):241-243. doi:10.1016/j.jcot.2018.02.014 31 arthroscopic double-row repairs with all-suture anchors 1.4 mm anchors were used in 8 cases and 2.3 mm anchors were used in 23 cases The postoperative Constant score was 77.1 Two cases of anchor pullout were observed intraoperatively, which was solved with a different location of placement No cases of postoperative anchor failure occurred Takeaway Functional outcomes with all-suture anchors are comparable to hard-body anchors Ro K, Pancholi S, Son HS, Rhee YG Perianchor cyst formation after arthroscopic rotator cuff repair using all-suture-type, bioabsorbable-type, and PEEK-type anchors. Arthroscopy. 2019;35(8):2284-2292. doi:10.1016/j.arthro.2019.03.032 213 single-row rotator cuff repairs were reviewed with MRI postoperatively to compare the appearance of all-suture and hard body anchors 137 patients received 2.8 mm all-suture anchors 36 patients received PLLA anchors 40 patients received PEEK anchors There was no difference in functional outcomes based on anchor type No differences in perianchor reactions were observed Bone cysts were seen in 8.8% of all-suture anchors, 16.7% of PLLA anchors, and 12.5% of PEEK anchors No differences in retear rates were observed Takeaway Bony reactions are uncommon with the use of all-suture anchors and comparable to that seen with hard-body anchors Ro K, Rhee SM, Kim JY, Kim MS, Kim JD, Lee H, Rhee YG All-suture anchor settling after arthroscopic repair of small and medium rotator cuff tears. Am J Sports Med. 2019;47(14):3483-3490. doi:10.1177/0363546519886547 88 single-row repairs with all-suture anchors were evaluated at various timepoints for anchor migration An immediate post-op MRI was obtained 2 days after surgery Follow-up MRIs were performed 10 months after surgery Bone mineral density was divided into 3 groups Anchor settling was a mean of 1.3 mm to 3.8 mm depending on bone mineral density There was no difference in rotator cuff healing between the groups based on bone mineral density Takeaway While slight anchor settling occurred postoperatively, the magnitude of migration was small, not exceeding the 5 mm value considered consistent with risk of cuff failure, and postoperative rotator cuff healing remained high Note: It should be recognized that these were single-row repairs. Double-row repairs with lateral knotless anchors may further shield medial anchors from migration. www.arthrex.com © 2020 Arthrex, Inc. All rights reserved. DOC1-000448-en-US_A

All-Suture Anchors for RCR Scientific Update

Knotless Labral Repair Scientific Update Knotless techniques have become the gold standard for arthroscopic labral repair. Biomechanically, a knotless technique leads to improved loop security (maintenance of a tight repair) with equivalent load-to-failure compared to knotted constructs. Clinical advantages of knotless repair include decreased risk of knot migration, decreased operative time, and restoration of function. As technology has improved, the ability to achieve knotless fixation has become available in smaller anchors. Biomechanical Studies Hanypsiak BT, DeLong JM, Simmons L, Lowe W, Burkhart S Knot strength varies widely among expert arthroscopists. Am J Sports Med. 2014;42(8):1978- 1984. doi:10.1177/0363546514535554 • This study had 73 expert surgeons tie 5 knots using their preferred technique. • The mean load-to-failure was 231 N. However, the range was 29 N to 360 N, and the standard deviation of the individual surgeon ranged from 6 N to 133 N. • Variability persisted regardless of whether the surgeon performed more than or less than 200 arthroscopic cuff repairs per year. • Only 37% of surgeons had an average load-to-failure within 20% of the mean, and only 18% of the individual knots had a load-to-failure within 20% of the mean. • Takeaway: There is considerable variability BOTH between surgeons and within knots tied by surgeons using their go-to knot. Denard PJ, Adams CR, Fischer NC, Piepenbrink M, Wijdicks CA Knotless fixation is stronger and less variable than knotted constructs in securing a suture loop. Orthop J Sports Med. 2018;6(5):2325967118774000. doi:10.1177/2325967118774000 • In this study, 34 surgeons completed suture loops either by tying knots or creating a knotless construct with a 5.5 SwiveLock® anchor and #2 FiberWire® or FiberTape® suture. • Load-to-failure was the highest with the knotless FiberTape technique (276 N compared to 161 N/151 N; P < .001). • Load to 3 mm of displacement (indicating loss of loop security) was higher with the FiberTape technique (199 N) compared to the knotless FiberWire technique (90 N; P < .001) and knotted FiberWire technique (59 N; P < .001). The difference between the knotless FiberWire and knotted FiberWire techniques was also significant (P = .024). • Variability based on a F-test for variance was highest in the knotted group. • Takeaway: Based on the assessment of multiple surgeons, a knotless technique with suture tape leads to improved construct strength, loop security, and reliability compared to a knotted or knotless technique with #2 suture. Martetschläger F, Michalski MP, Jansson KS, Wijdicks CA, Millett PJ Biomechanical evaluation of knotless anterior and posterior Bankart repairs. Knee Surg Sports Traumatol Arthrosc. 2014;22(9):2228-2236. • In this study, 9 matched cadaver pairs were used to evaluate 3 anchor Bankart repair constructs using 2.9 mm PushLock® anchors: - Native state - Repair with #2 FiberWire® suture - Repair with LabralTape™ suture • There was no difference in load to 2 mm of displacement or load-to-failure between the native state and either repair state. • Takeaway: A knotless labral repair with 3 anchors can restore labral biomechanics to that of the native state. Funakoshi T, Hartzler R, Stewien E, Burkhart S Remplissage using interconnected knotless anchors: superior biomechanical properties to a knotted technique? Arthroscopy. 2018;34(11):2954-2959. • In this study, 7 matched cadaver pairs were used to compare 2 remplissage repair techniques that create a double-mattress suture between the anchors: - A knotted double-pulley construct with two 3.0 mm SutureTak® anchors - A linked knotless construct with two 3.9 mm Knotless Corkscrew® anchors • Load-to-failure was higher in the knotless construct (788 N compared to 488 N; P = .003). • The mode of failure varied based on the construct. - In the knotted group, it occurred via suture breakage or slippage in 6 of 7 cases (tendon tearing) - In the knotless group, it occurred by anchor pullout or tendon tearing with no cases failing due to knot slippage or breakage Takeaways • A knotless construct with 2 interlinking anchors might improve the biomechanical performance of remplissage. • An interlinked construct transfers the weak link in fixation to the tissue and bone (no failures occurred via suture slippage as in knot tying). Kim SH, Crater RB, Hargens AR Movement-induced knot migration after anterior stabilization in the shoulder. Arthroscopy. 2013;29(3):485-490. doi:10.1016/j.arthro.2012.10.011 • This study involved 10 consecutive 3-anchor knotted Bankart repairs, which were performed to evaluate knot migration following cyclic loading. • Knots were placed as far anteriorly as possible at the time of repair. • Following cyclic loading, knots were significantly close to the anchor (closer to the articular surface). • Also following loading, the knots faced the joint in 5 of 10 of the inferior knots, 7 of 10 of the middle knots, and 6 of 10 of the superior knots. • Knot loosening also occurred in 4 of 10 of the inferior knots and 1 middle knot. • Takeaway: There is substantial potential for knot migration toward the glenoid following Bankart repair. This may have implications for postoperative development of arthritis due to knot-cartilage abrasion. Lacheta L, Brady A, Rosenberg SI, Dornan GJ, Dekker TJ, Anderson N, Altintas B, Krob JJ, Millett PJ Biomechanical evaluation of knotless and knotted all-suture anchor repair constructs in 4 Bankart repair configurations. Arthroscopy. 2020;S0749-8063(20)30128-6. doi:10.1016/j. arthro.2020.01.046 • In this study, 30 cadavers were used to compare knotless and knotted 3-anchor Bankart repairs in different stitch configurations. - 6 cadavers used to test native state - 6 simple configuration knotted constructs – 1.8 mm Standard FiberTak® anchor - 6 simple configuration knotless constructs – 1.8 mm Knotless FiberTak anchor - 6 horizontal mattress configuration knotless constructs – 1.8 mm Standard FiberTak anchor - 6 horizontal mattress configuration knotless constructs – 1.8 mm Knotless FiberTak anchor • There was no difference between knotless and knotted constructs in load-to-failure. • Strain of the native state was most closely reproduced by the knotless mattress configuration, which was the only repair that did not result in increased strain compared to the native state. • Suture slippage occurred in only 11% of the knotless constructs compared to 30% of the knotted constructs. Takeaways • A knotless Bankart repair with 1.8 mm Knotless FiberTak anchors results in biomechanical performance equal to a knotted construct with low rates of suture slippage (maintenance of loop security). • Knotless horizontal mattress configurations increase biomechanical performance compared to simple suture configurations. This configuration is capable of achieving strain levels not statistically different from the native state. Nolte P-C, Midtgaard KS, Ciccotti M, Miles JW, Tanghe KK, Lacheta L, Millett PJ Biomechanical comparison of knotless all-suture anchors and knotted all-suture anchors in type II SLAP lesions: a cadaveric study [published online June 23, 2020]. Arthroscopy. 2020. doi.org/10.1016/j.arthro.2020.04.026 • Using 20 paired cadaveric shoulders for a standardized type II SLAP repair using the peel-back mechanism with the long head of the biceps (LHB) tendon, this study compared the tensionable, knotless all-suture anchor (group A: Knotless 1.8 mm FiberTak anchor with #2 FiberWire CL suture, Arthrex) and the knotted all-suture anchors (group B: 1.8 mm Q-Fix™ anchors, Smith & Nephew). • Mean load-to-repair failure was similar in groups A (179.99 ± 58.42 N) and B (167.83 ± 44.27 N, P = .530). • Mean load-to-ultimate failure was 230 ± 95.93 N (group A) and 229.48 ± 78.45 N (group B), and (P = .958). • Both knotless and knotted initially performed with high fixation strength. • Takeaway: All-suture anchors are smaller in diameter than solid anchors, so they can be inserted through curved guides, preserve bone stock, and facilitate postoperative imaging. Both knotless and knotted anchors performed similarly biomechanically in type II SLAP repairs. Clinical Studies Bents EJ, Brady PC, Adams CR, Tokish JM, Higgins LD, Denard PJ Patient-reported outcomes of knotted and knotless glenohumeral labral repairs are equivalent. Am J Orthop (Belle Mead NJ). 2017;46(6):279-283. • The SOS™ database was used to compare 321 knotted labral repairs (anterior, posterior, and SLAP repairs) to 489 knotless labral repairs. • Patient-reported outcomes were the same between techniques regardless of type of labral repair. • Operative time was lower in the knotless group. - 8 minutes lower for the anterior labral repairs - 24 minutes lower for the posterior labral repairs - 18 minutes lower for SLAP repairs • Takeaway: A knotless technique decreases operative time without compromising patient-reported outcomes. This may have important cost-savings implications given the high expense of operative time. Thal R, Nofziger M, Bridges M, Kim JJ Arthroscopic Bankart repair using knotless or BioKnotless suture anchors: 2- to 7-year results. Arthroscopy. 2007;23(4):367-375. doi:10.1016/j.arthro.2006.11.024 • In this study, 73 Bankart repairs performed with a knotless technique were reviewed at a range of 2 to 7 years postoperative. • The mean postoperative ASES score was 96 points. • Postoperative recurrence was only 6.9%. • Takeaway: A knotless technique for Bankart repair is associated with acceptable rates of postoperative recurrent instability. Recurrent instability in this series was at or below that reported in the series in which knots were tied. www.arthrex.com © 2020 Arthrex, Inc. All rights reserved. DOC1-000338-en-US_B Ng DZ, Kumar VP Arthroscopic Bankart repair using knot-tying versus knotless suture anchors: is there a difference? Arthroscopy. 2014;30(4):422-427. doi:10.1016/j.arthro.2014.01.005 • This was a prospective, randomized study of Bankart repairs performed at one institution. - 45 knotted repairs with 3.0 mm SutureTak® anchors - 42 knotless repairs with 2.9 mm PushLock® anchors • No difference in postoperative functional outcome. • No difference in postoperative instability. - 1 patient in each group had recurrence • Takeaway: Level 1 evidence demonstrates no difference in recurrence with a knotless technique compared to a knotted technique for anterior Bankart repair. de Groot SJ, Arner JW, Smith CN, Bradley JP Arthroscopic SLAP IIb repair using knot-tying versus knotless suture anchors: is there a difference? Am J Orthop. 2018;47(12):10.12788/ajo.2018.0101. doi:10.12788/ajo.2018.0101 • This study is a retrospective comparison of knotless to knotted SLAP repairs reviewed at minimum 2-year follow-up. - 42 had knotted repairs - 32 had knotless repairs • Return to play was higher in the knotless group, although this did not reach statistical significance (93.5% compared to 90.2%; P = .94). • Knotless anchors were less likely to require revision but did not reach significance (9% compared to 17%; P = .50). • Takeaway: A knotless technique leads to at least equivalent return-to-play levels following arthroscopic SLAP repair, and such a technique may reduce the risk for revision. Cordasco FA, Lin B, Heller M, Asaro LA, Ling D, Calcei JG Arthroscopic shoulder stabilization in the young athlete: return to sport and revision stabilization rates. J Shoulder Elbow Surg. 2020;29(5):946-953. doi:10.1016/j.jse.2019.09.033 • Prospective evaluation of 67 Bankart repairs in young athletes - 21 years or younger at the time of surgery - Athletes were included if they had 3 or less dislocations prior to repair - Repairs were performed with knotless anchors (PushLock) and a mattress suture configuration - A minimum of 3 anchors and mean of 3.6 anchors were used for repair • 94% of patients had no postoperative instability • 88% returned to their previous sport with 75% returning at the same level • Takeaway: A knotless technique with a mattress suture configuration and a minimum of 3 anchors leads to a low level of recurrence in a young athletic population

Knotless Labral Repair Scientific Update

Knotless FiberTak® Soft Anchor Technique

Knotless FiberTak soft anchors combine the benefits of all-suture anchors with knotless soft-tissue fixation. A tensionable, suture-locking mechanism allows users to control the repair tension under direct visualization.

Knotless FiberTak® Soft Anchor

Knotless 1.8 FiberTak With #2 Suture, qty. 5

Knotenloser FiberTak-Soft-Anker, mit #2 Faden, 5 Stk.

Tensionable Knotless Bankart and Remplissage Using Knotless FiberTak® Soft Anchors

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