LabralTape is a smooth, low profile, specialty suture that is made from polyethylene. This product pairs nicely with the 2.9 mm PushLocks and 3.5 mm SwiveLocks to provide a wider footprint on knotless repairs.&nbsp;
The release of 1.5 mm LabralTape complements knotless labral repair and is yet another way that Arthrex is helping&nbsp;surgeons treat patients better. &nbsp;

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Arthroplasty Shoulder

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Imaging and Resection

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Shoulder and Elbow - Next Generation in Repair and Reconstruction 2024

James E. Voos, MD, (Cleveland, OH) teaches the principles necessary for shoulder restoration using instability repair at the Naples Fellowship Forum. He shares technical pearls for patient positioning, portal placement and camera positioning. He highlights the use of the PushLock® anchor with LabralTape™ suture, the ShaverDrill™ device and the PushLock® Percutaneous Insertion Kit. Lastly, Dr. Voos shares SOS™ global data registry results that highlight the time savings that can be achieved with knotless techniques.

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Anterior and Posterior Shoulder Instability

Specifically talking about when we're fixing both anterior or posterior instability. So we talked yesterday about our professional football player. The same thing when your professional basketball player or other athlete comes with a shoulder dislocation, how are you going to best manage them so you can get them back out on the court? Particularly when you're down three games in the in the finals here. We talked a little bit about the anatomy here before, but I really wanted to reinforce the hammock effect of that anterior and inferior glenohumeral ligament and the capsule below, because that's really, I believe, what separates how we could do this arthroscopically and open is how you're able to manage the capsule. I think with careful techniques in the arthroscopic setting, we can mimic the open setting by really tensioning the capsule. You can fix the labrum the same way, open or arthroscopic. It's really how do you tension the capsule that gives you that additional success rate. So want to reinforce that Force that inferior hammock part of the capsule. We know through a lot of the work by Doctor Boileau and others, that there are ways to look to see which of your patients you can carefully select, to know who will do better with open and arthroscopic techniques. Obviously they do a lot of their procedures there, so it's really carefully assessing each of those patients, really looking at your radiographs to assure that you can cancel your patients appropriately. And these two studies, both for anterior and posterior instability, I think have really helped us to really boil down to a good number of what you can tell your patient that the instability rate is. And some of our most recent studies that the rush group did, they looked at collision athletes. When you have someone in the lateral decubitus position, less than 25% bone loss using more than three suture anchors, the failure rate was 7.9% for our anterior instability. Jim Bradley just did a systematic review looking at posterior instability in the appropriately selected patient they're in. The 26 study showed an 8% rate of recurrence. So that's that's a good number to remember for both in the front and in the back. In the appropriately selected patient it's 8%. Certainly if we're missing some of that bone loss such that those numbers can go up. But it's nice that that's played out for both our anterior and posterior instability part of things. So I trained when I was sitting in your seat at this course as a fellow I trained in, in the beach chair position, did everything in the in the beach chair. And you're able to access both. The TRIMANO does a great job holding the arm, but I have really converted in practice here to doing these all in the lateral decubitus position. So I've really even adapted since in fellowship. I think when you're when you're doing this in the lateral decubitus position, you can get symmetric with the shoulder. So one is with the arm. In abduction the key is not just the weight on the fingertips but at the armpit. The one pulling straight up really allows you to distract the shoulder. So you can use that straight abduction part of the of the device as well as your assistant pulling that traction. And then here this is in Doctor Ventures paper when you scope in scope in the lateral decubitus position. Try this in the lab. I stand at the head of the patient, so it's like you're riding a bike, right? So whether it's a right or left shoulder, anterior or posterior instability, you're operating the same way. So a left anterior is the same as operating on a right posterior. It's symmetric. It's easy. You can rest with your hands. If you stand behind the patient and operate like this, it's like you're wrestling a steer. And that's what I tell our wrestlers or our residents and fellows. It looks like you're trying to rip a steer down, and it's an awkward position to operate for a while. So to address both anterior or posterior instability, try standing at the head. And then you can work symmetrically. And it's very very ergonomic to do. It makes addressing things in the front and the back very easy and symmetric. Each time. We've talked to about two of these tools this morning that have really changed things, using the the ShaverDrill has really helped. It's one less thing you need to have on the table. It's very light and efficient to use, and always having the percutaneous kit available, particularly posterior, is when I use it the most, has really been a great tool to have. So those are always good things to have in the room. There are a lot of different ways to address our instability. Certainly, a lot of people still tie knots and there's no issue with that. But now with the two Knotless options really have helped. I've moved to using our push locks here and wanted to reinforce some of the things we just talked about. That portal placement really is the key, where you're putting that spinal needle, where you're almost going through the subscapularis. Getting as close down to that SpeedScap as you can. You'll see. I'll even almost try to come in behind the subscapular and sweep it out of the way to try to get as low as you possibly can. If I can't get down there before making that portal, that's when I'll use the percutaneous kit and go through the subscapularis. So it really does make a big difference there. The other part of assessing our teres both in the front and in the back. Don't be afraid to use your 70 degree scope or as we do in this case this is looking from the back. You see the labrum is off the front, but you're really not quite sure what the labrum looks like. We sneak all the way around the back. The best thing you can do is to go and take and put that camera in that anterior portal. Look from the front. Now you can look down and assess your bone loss a little bit more. You can assess what your labrum looks like. And now you can come and get all the way down to the bottom. And you see, as we're lifting that up, you can see the anterior inferior glenohumeral ligament. You can really free it up with your elevator. That way you can start to tension the capsule here much more. We talked a little bit about that traction stitch. So it looks like we're all the way down at the anterior inferior glenohumeral ligament with our with our lasso. So we shuttle that through. But you'll often find once you put that in and start to tension it, it pulls through the tissue. And it's not quite as low as you want it to be. So if you put your anchor in in that position, you'll find that you're going to be a little bit slack. You won't like how you've pulled up that inferior hammock. I think that's where some of our failure rates come, because we haven't appropriately pulled that, pulled the tension of the capsule up. So once we get this through, I'll pull on it and see, do we do we really like what that looks like? And if not, we'll come and put a second stitch in here to really get down even lower. So here we are pulling you see now when once we start to pull on it. So you could get down a whole nother clock face better. So now pulling those tension stitches, just like we talked about in the last talk. Now you can come get all the way down low. Really pull the capsule and the labrum up to restore that tension. And again, I think that's what helps separate us from our from our open and arthroscopic procedures. Now, now you can line up your anchor right where you want it to go. And this is the key I wanted to bring up with our PushLock. So I take and instead of putting the eyelet at the hole and pulling the suture over, I walk all the way over to the tissue and reduce your eyelet to the tissue and bring it all the way over so you can walk over and reset your tension then. So I have my assistant hold the camera. I hold the sutures in the anchor and bring it all the way over. That way you can really restore the tension. As soon as that eyelet goes in the hole there, you let go of the sutures and pound it in so you don't over tension it. But that's really helped to restore that nice bumper effect here to get those anchors in. Again, restoring that capsule tension has been very, very helpful. So then at the end we see that we've decreased that inferior axillary axillary pouch volume. And you can have a nice good bumper cushion with your repair. So try that in the lab today. One standing at the head. The second is that holding on to the suture and your anchor all at once to help the tension. This this is again looking through that anterior portal with our SOS database. We've talked quite a bit about how much time you can save with this. And putting in these, these anchors without tying the knots can be nice and nice and smooth. You save a lot of time with and our outcome scores have been excellent. With these, I would caution you this is the time in your career. Don't forget how to tie a knot. We use so many great knotless devices it makes things very easy, but still have those 1 or 2 different knot configurations that you're comfortable with. You never know when you're going to have to bail yourself out or do some of these other techniques. So don't lose that skill as to how to how to tie an arthroscopic knot. This is a time in your career what's good to have those still have those skills at hand?

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.

Posterior Instability Repair

So. Pathologies. Pathologic theories of posterior instability. There are many retroversion, chondrolabral, retroversion, humeral retroversion, Hill-Sachs lesions, capsular attenuation, muscular imbalances, and throwers is very common too, but usually in my mind is a combination of the above that gets them into trouble. So what we did is we did a meta analysis of the world literature, Jeff DeLong and I, and we found out that in arthroscopy, there's almost 700 shoulders in athletes out of 739. And of that group, we looked at what how many we published for other things. So this is kind of what I learned. So almost well, actually 50%, 58% of the athletic shoulders that were published in the world literature actually came from our group. So I just want to tell you what we kind of learned from from that. So the first thing I can tell you is because I always give things in tens, if you've noticed. So the first thing I can tell you is that the etiology and the overhand athlete of posterior Postural instability is frequently different than contact athletes. So Jim Toboni and I, in 93, when everybody else was studying anterior, we wanted to go posterior. And we found out that chronic overuse microtrauma to the posterior capsule, capsular attenuation and posterior subluxation was very common. And then and we looked at in certain sports and we found that football players actually had a high rate of posterior instability. And Lee Kaplan and I looked at the combine data from the NFL. And we found that surely that offensive linemen were the greatest, followed by defensive linemen much more than any other positions. There's a second group of throwers, and throwers are completely different groups. So if you take care of throwers, they're completely different than the rest of our athletes. And what they do is they initially get a tight posterior inferior capsule. They get repetitive microtrauma after ball release, and then they get this progressive tearing of the posterior inferior labrum, and then they get mechanical symptoms or pain during follow through. But instability is not one of the symptoms. And there's a third group that's going to come out that's all about muscular imbalances with a tight packs and overactive lats. So there are some. The second thing I can tell we learned is physical exam findings predict a poor result for posterior instability. Is this circumduction test where the arm is out the back and then reduces? If you see that I haven't gotten very many people better once that once they show you that test, the next one is when you have a load and shift in neutral and you have them on the table and they just pop right out the back like that. I really haven't had much success at all by fixing that or by helping them with physical therapy. I think the oh, you want to be aware of hypermobility states. Last year alone, I diagnosed six people with Ehlers-Danlos syndrome. So you're going to treat those much differently than you would treat the treat your normal athletes. The next thing is be aware of bone loss. And the question is how much bone loss is too much. Now we kind of know anteriorly 25% or so, but posteriorly we really don't know because I mean, how much is too much? 25% is only 7.25mm. So what we did was there's no clear answer from biomechanical data or clinical data in the literature at all. So we looked at our 200 posterior repairs that we did and decreased bony width was predictive of a poor result, but it had nothing to do with a number of how much glenoid loss was. So it was a narrower glenoid. It had a higher risk of failure, but not a specific number. And we're trying to look at that. J.t. Tokich and Matt prevention were going on. We're looking at it right now. And then the question is what about Retroversion. Well how much is too much? Well, I can tell you that by the literature. Before we did the study, there was nobody that had anything to say about Retroversion afterwards. And of our 200 patients, once you fix the fix them retroversion did not make a difference. It had no clinical outcome once you fix them. Arthroscopically. So we looked at these again with Craig Morrow, and we wrote a paper on it and looking at our MRIs and the final result, there was no significant differences in scores for version, either bony version, retro version, or ChondralDrill version, and the only thing that was a predictor of poor results was decreased with the glenoid. The question then came to mind is I'm saying, well, there's got to be a number. It's 13%, 12%, 20%. We looked at ours and we found that there was no correlation between bone loss and poor results. Once you once you fixed them. So what we're going to do now is take preventers and kicks and my patients all together and use it one specific technique for bone loss. And see if we can give you a number the next time around. I will tell you that Brett Owens did a great study on risk factors for posterior instability in young athletes. And the most significant risk factor in active young athletes is an increased retroversion. So for every one degree of increased retroversion over the normal, there's a 17% risk of subsequent posterior instability. So it looks like pre-op. It makes a difference post-op. It didn't make a difference in our study. Ben has taught us beware of scapular dyskinesias in these people, because a lot of times they're going to present with scapular dyskinesias or winging of the winging the scapular, but all they're doing is protecting their their shoulder from going out the back. So you literally have to it gets scary, but you literally have to fix the posterior instability for the for the scapular dyskinesias to go away. In throwers protraction is very, very common. So you got to accept protraction that they're going to be protracted, especially in pitchers. But what happens is, is they get a tight pec in the front and their lats just overpower the back and pull. The capsule can't restrain it and it just pulls them out the back. So be careful when you do your physical exam to look particularly at a tightness in their PEC major and minor. The third thing I can tell you is that labral tears and retroversion, both bony and condor labor are common. They're not rare, as the literature says. So we've done we did multiple studies about labor lesions. And the first 100 patients we published, 57% of them had some sort of labral lesion. The fourth thing we learned is that posterior pathology is rarely isolated. It comes in combinations with slaps, slabs, partial cuff tears, reverse Hagel lesions, posterior glenoid and linebackers. So of our four over 400 patients on our current prospective study that we've operated on, over 40% of those had some additional pathology that needed to be addressed at surgery, whether it be a sleep aid or a partial cuff tear. Beware of of posterior avulsions. Okay. So reverse lesions, if you look pre-op on the MRI, you can see this large reverse Hagel lesion. And you have to preoperatively prepare a little differently for him than some others. And here's some concomitant lesions that we saw once from baseball a prior thermal and football. So you've got to be prepared for these capsular rents as you go along. The fifth thing I can tell you is that overhand athletes have poorer results and outcomes and return to sport. So if you look at the overall literature, when we looked at it, there were small numbers. They were not well documented and most of them did not fare well if you were an overhead athlete. And then so we looked at ours. So we thought we were a little better. We weren't we? If we looked at our first 27 throwers and published it, and we found out that 55% of our throwers were less likely to return to their preoperative sport. And when we looked at the 200 and we said, okay, in the 200, there were 56 overhand athletes. And the important thing we found out is that if you had a suture anchor repair, you had a 70% chance of going back. If you had an anchor less repair in a thrower, you only had a 22% chance of going back. So then we looked at a case match. So we got finally got enough people in our study that we could, we could case match two sets of people of throwers versus the whole group. And we took 48 of them throwing athletes and 48 non throwing athletes. They were perfectly matched groups. And we found out that throwers 85% returned to the sport and non throwers 87%. Not too bad right. What is bad because only 60% returned to the same level in throwers, and only 70% returned the same level in the whole group. And we're talking about the exact same level of playing now. Not not just playing. So then what about pitchers? Pitchers actually had better aces, pain score, stability, functional scores and were in general were better results than the whole throwing cohort that we looked at those against. But the outcomes were worse. 50% of the pitchers returned to sport versus 85% of the entire cohort. But 33% of the nine that returned returned at a lower performance, and 17% didn't return at all. So pitchers are one of the hardest ones to control for posterior instability. What I will tell you what I learned in the end. In the end, in throwers, to loose is always better than too tight and overhead. In athletes in contact athletes, they have better outcomes and better return to sport. We look at our 200 and we had 117 contact athletes. 93% of those went back, so they're a much better group. We looked at them and published on them of arthroscopic stabilization of posterior instability and is successful in American football players. We had a 93% return to sport and 79%, which is a good number for me, returned to sport at the same level, and a lot of these were college and professional athletes. So in the end, in contact athletes tight is always better than too loose in those because actually the offensive linemen like it because they can hold a little better because they don't have as much external rotation. So what about arthroscopic versus open? I can tell you this that arthroscopic treatment is better than open, especially in overhead throwers. Why do you do arthroscopic stabilization? Because you can return because you can do concomitant pathology. So partial cuff tears, slap eight lesions, capsule rents and haggles in the literature. Overall, it has lower recurrence rates and improved perioperative morbidity. So how do I do it. There's two ways I do it. That's what it kind of looks like in the back when you get there. I don't think we spent enough time abrading and taking care of the posterior labrum to kind of upset it. This is a cutaneous technique called the hot, what you also call a hybrid. We call it a zone specific. So we'll put a two for. Anchor in the bottom one because you can get a better Line to the glenoid. We use this real pass. If you haven't used real pass, it's really the angle is really good. It's a really small thing. They have it out there. It's called real pass. It's got about I don't know, ten yards of material in it. You can use. You can, you only need one. And then you just flip it around. And I use a sliding Weston. Not a little small not locking sliding locking not. And you can see the very small little portal we use. And then for the rest of the repairs I'm a big LabralTape fan. Labraltape is 39% stronger than that. Suture has a 37% greater pullout strength from the labrum, and that's where they usually fail. So LabralTape has really changed the way I do it, and I'm faster with it. So I would put one one on the bottom with the two four anchor, and then I'll have three labral tapes going up the back, and that usually will fix it. But you can see the the nice contour that you can get. Don't worry about the bumper. The bumper goes away. Everybody worries about the bumper. I always close the posterior portal because it's a stress riser. In the early revisions that I did, I would go in there and I'd look and I'd say, what's that big hole doing there? It just never filled in filled in correctly, so I always will close that with some PDFs. Now the other thing you can do is this is you can use a cannula, a lower cannula called a low profile cannula. And you can see it down there really low. There's another cannula and it's about three centimeters away from the axillary nerve. I did the dissections. So in small people I use a hybrid. And my big athletes typically I use the this technique here where I'll use LabralTape the whole way through. You want to get the the anterior or you want to get the posterior band of the anterior glenohumeral ligament. You want to get the anterior portion of it first, and then you get the posterior portion. And you can see that it reforms itself very well. And the problem with these athletes is they want to go too fast. You got to slow them down. The procedures you can do with arthroscopically are many. But what I would tell you is this don't do thermals with it. Don Lozano and I did the study back in, I don't know, it was 19, 2004, and we had a 40% failure rate when we used any type of thermal. So don't do that. We looked at our 2005 prospective study of 100. We had 91% good, excellent results. 86 returned to sport. Then we went to 200. And in the 200, it was quite clear to us, even from the 100, that the suture anchor group had a significantly better Aces score and had significantly better return to sport than the non suture group. So the literature summary of open versus arthroscopic arthroscopic wins in every way. So you really should think about doing that at recurrent instability. Ability to address concomitant pathology perioperative morbidity return to sport and cause diseases. Number eight the rotator interval rarely needs to be closed. It's just like in multidirectional. I still don't close it very rarely. So our first hundred athletes I did seven rotator interval closures. I probably those patients were really the MDIs which you saw before. I was just learning. The second 200 patients I did none. And they did have had a better result. And then Matt Preventer bailed me out and said, look, that he won the Air Cast award for this. In a study with the addition of a rotator interval closure after arthroscopic repair of anterior and posterior shoulder instability. And he said in the study that won the award, this study calls into question the need for an arthroscopic rotator or arthroscopic rotator interval closure in the setting of posterior instability. And I'll tell you, you don't need to do it. The ninth thing I learned is, when in doubt, use suture anchors. And the reason is that in all of our studies, overhand athletes, football players contact the anchor group had a significantly better ace score at the end that had a significantly better return to sport in every paper we did. The 10th thing is, I'm going to tell you is you're only as good as your physical therapist because they see him as a movie picture. You see him in snapshots. So get get your therapist out there that are good at taking care of these and make you look better. So indications for surgery, a failed rehab greater than six months, a large labor or flap tear on the MRI that you know is not going to get better. Posterior glenoid bone loss of greater than five millimeters. In my mind, I start thinking they're going to. That's what I've been using about 15% right now, but I don't know if that's the right number. That's just all Gestalt reverse haggles are or posterior capsule rents you have to address. They're not going to get better. So once you see them, you're going to have to fix them. And you're and the inability to return to sport at the same level. So the questions I'm commonly asked is when to anchor. I almost anchor all the time now. I use anchors all the time. When and how much to placate depends on the sport. Football aggressively throwers rarely when to debris. If you have a large flap tear with a stable rim, sometimes in throwers you can just debris the flap and you don't need to do anything. The hardest question is when to fix the labrum and release the posterior inferior capsule. That's about an hour long lecture, but when I have a labral junction tear, excuse me, and a significant internal rotation deficit, I will fix the labrum and then just cut the posterior band right above it, about five millimeters off it, and throwers to get their internal rotation and when to close the rotator interval. Really only in true MDIs if you need to. And I have really never done an interval closure in a thrower with a posterior capsule lesion.

Stephen S. Burkhart, MD, (San Antonio, TX) highlights the benefits of the latest, knotless technology with the Knotless SutureTak® device and PushLock® anchor with LabralTape™ suture for instability repair. Dr. Burkhart also shows how to use the new percutaneous insertion kit to place anchors low on the glenoid.

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

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

Operationstechnikvideos

Gravação em vídeo de uma técnica cirúrgica em um paciente em uma sala de cirurgia ou uma demonstração cadavérica.

Vídeos de técnicas cirúrgicas

Grabación en vídeo de una técnica quirúrgica de un paciente en un quirófano o una demostración cadavérica.

Videos de técnicas quirúrgicas

Surgical Technique Videos

Knotless Instability Repair Utilizing Knotless SutureTak® and PushLock®

We're going to show you some of the newer techniques for instability repair. We're going to try to focus on some of the newer nautilus fixation techniques that are very secure. There are a couple of types of LabralTape. Now we have the one that's just plain white sometimes. So you want to put something that to show it. And it helps you as a surgeon to to see it better. So we have this TigerTape that will show up better. We've got these QuickPass suture passers that have the nitinol. You heard about the real pass. We're going to probably be using these QuickPass ones today. It's another option for you. This is the PushLock. It's the one that we use with the LabralTape. It has the 12.5mm length to it, so it has fewer barbs. This is the Nautilus SutureTak here. This is a 3.0mm diameter. And we'll be showing you how to use it a little bit later as we start to put one in. But this is one of the newer products here that was just launched. And then we have the percutaneous set. If you want to use a percutaneous anchor placement. And you start out with a spinal needle to localize it, and then you dilate up and you get all the way up to this metal cannula so that you can pass your LabralTape and PushLock through that. It's large enough for that. So we'll try to show you how we use all of these things here today. It's the left shoulder. And I have a couple of those spinal needles. Pre-placed. This is the posterolateral portal for placing an anchor even down towards 6:00. So you see, the angle of approach is much better for anchors than the standard posterior portal would be. And then this is our 5:00 portal. Even though on the left shoulder, on the face of the clock it's not at 5:00. But that's what Jim Tiboni called it when he described it goes through the SpeedScap. It's a trans SpeedScap portal to get a better angle of approach down to that anterior anterior part. This is our antero-superolateral portal. I have it posterior to our biceps. Here is our Gemini cannula in the front. It's very useful in these instability cases. Now this is a shieldless arthroscope that's more rigid for instability as I put my three cannulas in and just switch my scope from one to another without having to worry about changing sheaths or using a switching stick or anything. I've done the prep already, but you want to want to get all this fibrous bands off, so you're all the way down to SpeedScap muscle belly, and that will allow your labrum to float up to the level of the glenoid. Sometimes your articular cartilage sort of overhangs the edge of the corner. And so I'll take a little time to get that excess articular cartilage, even to the point I may have a little two millimeter track toward the face of the glenoid. That allows me to know that I'm getting my anchor just beyond the corner of the face. Now, here's one of the problems, potentially. Say you want to get an anchor in it anterior inferiorly, and that can often be a very steep angle, even if you've lost a little bit of bone. It's particularly steep, and it can be hard to get good purchase there for your lower anchor. So you may want to consider a 5:00 portal. This is the angle of approach you would have through the cannula. And look at what a direct approach you've got with that lower TransFix GAP portal. So we've got our spinal needle in there, and we have a little small obturator that goes in through the spinal needle. And then it comes out into the joint. Now we can take our spinal needle out. Now at Now, at this point, you need to make a little stab incision alongside that little obturator so you can get your dilators in there. And now we're going to dilate this up. And now we'll just dilate with our spear. And you see over the top of our spear, we have that 4.5in diameter metal cannula that will allow us to insert some instruments as well. And now we need to push that cannula down as well with it. So now we have everything down in there. The next thing I want to do is we're going to go ahead and place our LabralTape. So we'll take a quick pass. So I'm going to come through my standard anterior portal. And we'll just pass that through the poster portal. Bring it out. And we're going to thread this LabralTape that has the black line in it, the TigerTape. So I'm just going to get my tape limbs out now first. And so now we want to go ahead and drill for our PushLock. So we're going to put our spear guide through that metal cannula. And we'll just drill right there. Okay. We have this small tape retriever that will fit through this small metal cannula, and we'll withdraw that. And now we can thread our PushLock. It has that little orange passing tab that will help you to get it through there. Just have a little bit of slack before you start to impact it. Okay. So you hit it down until the first thread hits bone. And then you take that little orange tab off the top, and now you impact it the rest of the way down to the line. And then you just 7 or 8 turns counterclockwise and that's it. There's a small tape cutter and it's so small it actually goes into that little hole you drilled to some extent. So probably that's what I'm going to do next is I'm going to get my most inferior anchor. So now we put that rod down there. So you want to make a little skin puncture right alongside there. And then we'll get our first dilator down there. And you need to visualize it. Need to be sure it went all the way down. I'm going to go ahead and put in that same assembly. We're going to use the spear and we're going to use that little metal cannula as well back here. You know, up until now, we used to always say, well, in order to tension things inferiorly, you need to tie knots. And with this knotless SutureTak, that's not necessarily the case anymore. There's a nice animation that shows how it works, and you see how you pass the suture through the labrum. It has a nitinol threader that comes through the body of the anchor, and it goes through and pulls that suture through the sheath. So it ends up it's a TightRope technology that basically is a suture core in through the sheath. So it ends up being like a Chinese finger trap in terms of tensioning it. And it won't pull back on itself. So it's a no slip knotless type of a loop there. So now let's go ahead and drill this, see how you can get all the way down to a 6:00 position. And that's just another reason to maybe take a little bit of the cartilage off. So you have like a like a two millimeter track of bare bone to aim at. But if you want a 6:00 anchor, you need to do it from a posterior lateral portal. So now we'll put the anchor down. I'll take out the spear also. Okay. So now if you look out through this canyon, you see what we've got. We have two nitinol limbs. One has a loop on it and the other one is straight. So what we have to do is pass the suture through the labrum, and then we're going to thread it through the anchor with the nitinol. I'm going to use this QuickPass suture passer and see how I can get right down at 6:00 to pass this. You don't want to go real deep. You just feel it pop through and then you come through like. So I'm just going to bring these out one at a time so I don't get things tangled. And then I'll use my tape retriever. We could have used the suture retriever again, but this just has a little bit less friction to it. And we'll pull that out on the outside view. We're threading that suture through the nitinol. And now we'll bring that up and through the labrum. We'll just pull the slack out there like so. Now, what we want to do is bring that back up through that working cannula where the nitinol wires are. So now we want to thread this suture through the looped nitinol limb. And there's a white part here and it's a little thinner before the markings start on the suture. So you want to double it over on itself back in the white thin section. And then what you'll do is you'll pull this down until it gets to the anchor. And once it's there, then you have a series of short little tugs like that to thread it up and through, and it comes back, and then you can tighten it with that. Okay. Okay. So now what we're going to do is pass our LabralTape. Now generally you're going to want it for the anterior lesion. You're going to want to have three anchors. I think for demonstration purposes, I may just show two today, recognizing that there would have been one above this. I just want to come up enough so that we'll avoid that last anchor. We'll hold tension in that tape while we drill. Now, if you have to lever the humeral head, you'd want to use a SutureTak. You could use a knotless or the knotted SutureTak. Because what happens? You'll see when we put this PushLock in, you don't have a spear to lever with. So it's just the anchor itself, and you can end up breaking the anchor if you're depending on being able to lever against the humeral head. So that's just a little precaution there for you to be aware of. Now, if you have trouble seeing we'll come around here. And if you can't quite see around it, I could switch to a posterior viewing portal to you see how nice and robust that repair is? And now we'll go ahead and cut this with our tape cutter. And like I was saying, the tip of this tape cutter is small enough that it basically fits down a little ways into that hole. All right. And what I'm going to do here, now, let's do one more of the Knotless SutureTak just so you can see that again. So now we'll drill that back here and we'll make it closer inferior. And so now we'll go and we'll pass this with a QuickPass suture passer. Again it's nice to have all these things in your armamentarium because there are some cases where you don't have good quality tissue or you think you might think things are under a little bit of tension to where you need to have to suture limbs. So now we've got to bring our suture back through here. And now what I want to do is thread the suture through this nitinol loop, turn it back on itself, and then we'll pull it through the anchor body. Now short tugs once we're down below the surface. And now we're through. And now we can just tension it. See, I put the anchor a little bit away from the articular cartilage on the first one, because I took on this cadaver a little wider strip of articular cartilage away than I would have in a real patient. So this is another thing that you can potentially do. You can grab the tissue and help reduce the labrum and then tease it up there even a little bit more like that. So you can get a really nice tight repair that way. You know, I think this is how you can get a knotless anchor down low, because there's no way you could do a PushLock because of the angle. You can't do a 6:00 PushLock with LabralTape, but you can certainly do a 6:00 Knotless SutureTak.

Jim Bradley, MD, (Pittsburgh, PA) shares his latest thoughts and discusses the top ten lessons he has learned over the past eighteen years in treating athletes with posterior instability from high school to professional level. Dr. Bradley shares his thoughts on the etiology of posterior instability, the impact of bony pathology, available treatment options, surgical pearls and published outcomes.

Posterior Instability of the Shoulder in the Athlete

Mark Ferguson, MD (Johannesburg, South Africa), shows some of the unique modes of instability injuries faced by the rugby players he commonly treats. He describes his preference for open Latarjet over Bankart repair for this patient population. Dr. Ferguson commonly starts the procedure arthroscopically to perform the capsulolabral release and repair any other pathology. He commonly finds posterior labral tears which he repairs with a knotless PushLock® and LabralTape™ before moving on to the open Latarjet technique. He also describes his success in using the Wedged Profile Plate to allow for compression of the graft onto the glenoid.

Latarjet for Treatment of Instability in Rugby Players

It was with great relief when Doctor Burkhardt and Doctor de beer came up with this groundbreaking article in 2000. I thought I could really dump a lot of more of my failures into those undiagnosed bone loss. I'm the sort of treating physician for one of our professional rugby teams in South Africa called the Lions the Golden Lions. That's one professional side. And then three junior and developmental sides. So quite a large pool of people and their medical staff can easily pull up all their history for me. So we thought we would just take away all those dislocations with bone loss. But even after excluding those, we still had a 20% dislocation rate. So for those of you, as you said, who don't see a lot of rugby, there are two main mechanisms which create the instability in rugby. The first one is try scoring. When we cross different to the NFL. When you cross the end zone or whatever it is, you've got to ground the ball. This can either be just be placed down, but always just a lot more spectacular. If you actually dive on the ground as this guy shows. And that's the normal way we do it. This obviously in the tackle situation, if somebody is on you at the same time, this is one of our international players here. He's got the ball under the affected arm with somebody on his back and abduction externally rotated. That's the sort of classic dislocation we get. Unfortunately not only that side these some of these players we don't have any other protection. We can't use harnesses. This is the other arm trying to protect them, which dislocates the other sort of situation is what we call the kick retrieve. There's a lot of kicking to try and win territory. And this competition for the high ball often result in a lot of injuries, obviously coming down on the top in those positions. This is actually one of our players coming down in the black. We had a sort of full 360 dislocation following that. Those are more the sort of acute dislocations. The other type of sort of instability we see are those repetitive trauma. And that's from the tackle. Now tackle I'm sure just the same as NFL. We love the big hits. And the bigger the hits obviously the better they are. But you know, they they're not bright. So they tend to enjoy it. But in these sort of the classic sort of tackles. Yes. Using the shoulder. So that there's actually no external rotation or horizontal adduction force against it. Obviously the quicker it gets and the larger the people get any sort of contact with the sort of upper arm. This is the Tecla, as the sort of contact point takes place further down the arm. That arm gets put more and more into external rotation. And these are the more the sort of repetitive instabilities we see. Microtrauma which eventually lead to often a dislocation. But there's long standing trauma underneath that. And this one you'll sort of see again the tackling arm. The contact point is further down the arm, not on the shoulder. And again, resulting in sort of instability with the arm closer to sort of 90 degrees of abduction most of the time. The other place where we sort of see this repetitive instability is what we call a ruck. When the ball goes dead or somebody gets tackled. You can still compete for the ball. We don't have another first down or anything like that. So in this sort of case where you get sort of tackled, somebody can then that's the ruck and somebody can. Problem is a lot of people don't really see what's happening there. And anybody can clear you out of that ruck. And that's where the other sort of area of instability occurs. So although we've still got that 22% redistribution rate I wouldn't thought I'd better go and have a look what the rest of the literature says. And as my great mentor always tells me, listen to those people who know more. So these articles and shows and these articles looked at those collision sports, those treated arthroscopically 29% had a dislocation rate and injuries where they looked at open and arthroscopic bankart repairs. Those done Arthroscopically had a 25. So those were sort of keeping. But why is this occurring? Was it my technique? I sort of looking at the previous speakers. I try to address all the pathology in my arthroscopic technique involving a good glenoid preparation, complete capsular label release my sort south to north shift using sufficient anchors properly placed and obviously ensuring that we had not loose security. So I looked at literature there and Pascal and Tauber have a look at it, and they looked at the sort of causes of recurrence. Those ones we know the hyper laxity, the bone loss, the number of anchors. But what we find is the amount of capsular damage. Marie Lorraine, one of my colleagues in Argentina who treats all the rugby players in his first paper, that he came out in acute dislocations. He only had a 4% dislocation rate with arthroscopic repair, which I thought it was quite incredible. If we look at his data, one 100% of those players actually had some capsular pathology, pure capsular tear in 4%, those with partial labrum 31 and a capsular tear and a complete label defect in 65%. So that's a seemed to be the most common thing. So if I looked at the risk factors at that stage? Yes. As we've all expected, with age, the amount of bone loss in the glenoid and the humeral side, the hyper laxity and the what concerned me was maybe it was a biological failure. I'm sure we've all sort of seen these where we go in there and there are multiple sutures and anchors, but there doesn't seem to be any signs of healing. So following this, I then embarked on what I call a daft a double row anchor fixation. I try to increase the contact pressures of the glenoid. These were all patients with multiple dislocations. Did double row labral repairs. They were all rugby players under 25 years, but I still had a 14% failure rate after two years. So that wasn't doesn't seem to be the construct. It just maybe just couldn't withstand those forces. What were the forces? Yes, they do seem to be excessively high to the to the impact forces. We don't they don't have any pads. Arm is more abducted extended than most of the times in NFL. Instability is typically at the end range. There are a lot of associated pathologies and to return to sport they need strong repairs. So I sort of sort of changing my selection from 2009. My only arthroscopic repairs were those with a documented acute first time dislocation, no glenoid bone loss, no humeral bone loss, and a shoulder severity index of less than two. The advantages I thought of this were. Yes, this is the ideal sort of healing response. This is the typical rugby player. We sort of see these 270 or sometimes even 360 degrees all at once to do is actually just be put put back in the right place. Also sound exactly the same. We find a lot of I get a high percentage of associated lesions and capsular lesions. Those mid capsular, far lateral, capsular tears are all associated. And these can be treated directly as well at the same time. And my sort of philosophy. Is yes, we're not trying to tension the capsule by shifting the Room. We can actually attend to that label pathology at the same time, if you can see it normally, those with multiple dislocations, the label, I mean the capsule pathology is already healed. And then obviously if we can do this, we can avoid these late sequelae of bone loss and excessive degeneration. So that leaves what when I do my lab and at the present all rugby players and if they have one risk factor, either one of those, they all going to get an open bony repair at this stage. So I've sort of really have crossed the Atlantic. I've gone closer to my sort of French colleagues and being a little bit more aggressive in my selection, my technique is yes, usually do everything in the, in the lateral decubitus. But I had to learn how to do the beach chair. I use a TRIMANO device to hold the arm. Makes it easier to take in and out easily assess if it's engaging or not. I usually do this dry before I put the water in to see if there's any release. And then at the same time, I can attend to any posterior label. Most commonly, these are posterior. I like using a lot of the knotless anchors with the LabralTape, which speeds things up, and if there is any posterior, I do close that, as David says, the posterior portal. And then what we'll do, which I think's helped me immensely for I really struggled. We all feel uncomfortable doing open surgery after being exposed to arthroscopic surgery for so long. And the hardest part I've always found about the latter is actually the capsular release when you do it openly. So I thought, well, why don't you do this? Arthroscopically we all know how to do it very well. So I do my capsular relief. I want to be able to see my GAP showing through. This only needs to be about 22mm, which is the size of my Fukuda retractor. So theoretically, the idea is as soon as you do your split, you should fall into this as well at the same time. For my open letter. I do a standard deltopectoral approach. It's normally about a 3 to 5 centimeter starting just below the coracoid tip. Routine approach I think we're all used to this deltopectoral approach. The first thing obviously we're going to do is try and expose our coracoid. After taking our vein, the most important thing is, as I said, exposing the coracoid to put a retractor above. What I want to be able to see is I'll pick minor attachment, which I normally relieve the cautery. There's always a small little bleeder right up at the top there, which needs to be caught as well. At the same time, in this sort of case, I'll come to it later. I'm trying to preserve a little stump of the ligament laterally, so I normally take about a one centimeter, the same as Jill Walsh. If I'm going to be using my inferior surface at this stage and my criteria, I'll show you them in the next slide. This is nice exposure. Especially if you elevate the arm slightly. You can normally get to it. I normally use an angled saw blade with a retractor, immediately making sure that my my saw blade is always pointing posteriorly. At this stage, to avoid any possible damage to the musculocutaneous nerve, I normally complete this once. I've just cut the cortex on the sort of medial and the sort of superior edge. I use a curved osteotomy and then can remove my bone block quite easily. Most of all of these are available in the sort of Arthrex kit. This is something that's just developed over time. As Doctor Burkhardt showed. That's what I want to see. I want to see that little spike of bone at the bottom, and then it just requires removal of my tissue on the medial aspect and the You asked him. It's quite easy. One can easily just release laterally. You're safe there as long as you don't go immediately. Then 1 or 2 strands. And that can normally free up your whole graft quite easily. To be able to use it when it comes to the graft. Now again, the great debate, the coracoid orientation. You heard Doctor Burkhart's speech. If we look at it, there are a number of sort of anatomical studies that have been done. The broadest surface, especially in the midpoint, is about 16mm. If you're using it in the congruent arc area, that area is about 13.5. So for the congruent arc you want to put it in that direction. Yes, it does give you the congruency as well, but it's not as broad a surface. So I try and customize this for each patient. If there's less than 10% glenoid bone loss, as I said, I'm not doing this procedure only for bone loss. I'm doing it for all these these patients. At this stage, with more than one dislocation, I'll use the inferior surface, which gives me my broadest Water surface and hopefully get some union as well. Those greater than 10% of ground loss. I'll use the medial surface, the congruent arc, as Doctor Burkhart says. That gives me slightly longer articular arc reconstruction as well at the same time. So for my coracoid. I prefer preferring this with a bur rather than a a with a saw that enables me to sort of try and establish exactly congruent surface. The idea of the bone clamp for drilling my holes makes it easy. Just want to ensure that we're right in the middle of it, just to protect her. Obviously, the skin behind you to drill both with the four millimeter and then the offset guides. Any problem with the offset guides? We get an eight. We get a six and a zero. If you are retaining some soft tissue, that can set you off a little bit. So I prefer using the zero offset guide, which is a bit more of a free freehand technique, and I can position the graft exactly where I want to. Taking into consideration that I do have a little bit of soft tissue there at the same time. When it comes to the sub scape, I normally try and identify the nerve inferiorly. There we can see it at the bottom of the picture. Use a nerve retractor and pull that out of the way. I do just a plain split between the lower two thirds, upper two thirds and the lower two thirds, just splitting it laterally and then just putting my mayo scissors down medially, still retracting the nerve. And then just using something simple like a swab on a stick. To just create that plane between my capsule at this sort of stage and I can put my Fukuda straight into the joint. I don't need to do any cutting or worrying about if I'm going to shorten my capsule, and that gives us a good exposure. We want to be aiming at around about the 4:00 position where we're going to be placing our bone graft. Again, I'll just use a small bur there. If we're going to be repairing our soft tissue, I normally place my one stitch through the soft tissue because it just makes it easier for later. And then using my zero offset guide, I can then position exactly where I need to to ensure that I create. I'm not too far medial or lateral on the coracoid. I use the wedge plate which I've used for nearly four years now. Not only I think does it give me sort of that confidence and in tightening my screws. It's not that finger tightness that everybody talks about. This is orthopedic tightness. You can really tighten this without any risk of fracturing that bone graft. From here on, it's fairly simple. We just drill over, drill with a cannulated drill and then put both our screws in. Same with the inferior hole. Doing exactly the same. My stitch is already down there, so all it does now requires is just removal of my Fukuda. As I said, this is the nicest part about me. I was always worried about how tight can one make this with a plate. It does give you that little bit of confidence because it has spread the forces across that bone. And fortunately, up until now, I've never fractured the bone block at all. Final check if we are congruent. Not much we can do about it now, but that's exactly what I want to do and see it at that stage. And then all K-wires is the closure of the capsule, leaving a small but four centimeter tear. Post-operatively we always check our position of our bone graft, as I said, wants to be in around about the 4:00 position post-operatively because I'm not actually opening the capsule. The substance detaching the subscapularis, my arm immobilizer is just for comfort. For two weeks they start immediate range of movement, and they can remove their sling anytime from two weeks and progressing ultimately to return to a rugby at four months. My results with this new technique. This is 58 shoulders. This is also including some judo as well. We're coming up to nearly two years, 12 of those with arthroscopic for the rugby players. We've had one dislocation where he fractured through it up until now, with the 46 open letter J's and the rugby players, we haven't had a dislocation rate at this stage. Once again, to Steve, thanks very much. We hope we can have you back in Africa. These were some lines which we followed hunting buffalo for three hours, but had to get on to a plane and we never saw the outcome. And finally, my last little bit of advice. Find out what it is in life that you don't do well and then don't do that thing. Thanks very much indeed, Steve.

Paul Brady, MD, (Knoxville, TN) shares highlights from a live surgery and demonstrates the speed, efficiency and security that can be accomplished with short 2.9 mm BioComposite™ PushLock® suture anchors and 1.5 mm LabralTape™. Dr. Brady describes the benefits of knotless fixation while placing nine anchors around the glenoid in only 30 minutes achieving a strong, low profile repair with no possibility of knot impingement on articular cartilage or rotator cuff tissue.

Knotless Pan-Labral Repair Utilizing the PushLock® and LabralTape™

Hi, this is Doctor Paul Brady. I'm from Knoxville, Tennessee, and I wanted to share with you my experience utilizing LabralTape and PushLock anchors for labor repair. Here I have a 27 year old male who has a type two slap tear with significant posterior extension. And then if we look at it through the Antero-superolateral portal, you can see he also extends down to the inferior and the anterior inferior quadrant of the labrum. In the process of labral preparation, I decompressed a large labral cyst. So I like to use LabralTape for several reasons. Number one, it gives a nice broad area of compression. Number two is it's extremely efficient as this video will show from a time perspective. This is so much faster than passing sutures and tying knots. And I've really gone away from knotted repair into completely knotless repair for my labral repairs. So here's anchor number two. You can see I come a little bit onto the face of the glenoid. When I'm passing these PushLock anchors, I utilize the 2.9mm short PushLock Anchors. There are two barbs shorter than your typical push locks. I like Biocomposite and I believe there are about 12mm in length, which for this 27 year old male with healthy bone is absolutely perfect for him. So here I'm completing the anterior inferior portion of the repair. We get our good fixation anteriorly inferiorly, and then we extend to the posterior inferior quadrant. It's important to work in this fashion such that you start in the anterior inferior, and then you work your way posteriorly, because there's a lot more room posteriorly than there is in the anterior inferior portion of the joint. I'm working through four portals posterior, posterolateral, antero-superolateral, and anterior. You'll see that I like the Gemini cannula in that posterior and the anterior portal, because it's got those flanges which not only keep that cannula from coming out, but it also helps you to retract the soft tissues. However, to place anchors into the posterior glenoid, this posterior lateral portal is extremely important, and I typically use a small crystal cannula through this posterior lateral portal. As you see, I'm just extending my way posteriorly, anchor by anchor, not making an effort to go fast. But you'll see it's just becomes very efficient. It's repetitive. You perform the same steps every time. It's very easy for you and for your operative staff. I'm doing this whole surgery with myself and with a scrub tech. I don't have any further assistance and we can be very efficient even with just the two of us. So here's the final LabralTape for my slap portion of the repair anchor number nine. And all in all, the procedure took just approximately 30 minutes to complete a nine anchor pan labral repair. So you can see in this final view from the anterior superior lateral portal that we have good reestablishment of the labrum against the glenoid. We have a good labral bumper circumferentially. And I believe if you can do an excellent job clinically as well as do it with some speed, it's really good for everyone.

Kyle Anderson, MD, (Detroit, MI) performs a knotless, 360° pan-labral repair and shares his thoughts on the importance of placing both anterior and posterior anchors inferiorly to reestablish the IGHL complex. He highlights use of the Torpedo Shaver for quick and clean labral and glenoid preparation. He discusses the benefits of knotless fixation and describes the post-operative trauma that can be caused by prominent knot stacks that either migrate towards the glenoid surface or impinge on the rotator cuff.

Knotless Instability Repair using the PushLock®, SwiveLock® & LabralTape™

So here we have a 47 year old guy who had subluxed his shoulder and had continued instability episodes despite physical therapy. You can see a rather large labral tear extending across the top with a large flap and then posteriorly as well. Very significant, essentially pan labral tear. Here we'll create a pan label repair, and I'll show you several ways that you can use Knotless technologies with PushLock, SwiveLock, FiberWire, and LabralTape. Here we have a Torpedo shaver, which I find is very useful at resecting bad tissue and leaving good tissue. It leaves a nice clean cut and can function much like a scissor. It is very adept at getting underneath the labrum in the superior to to debris the superior glenoid. This has helped me to prepare the labrum and glenoid much faster than ever before. Here I've passed a monofilament through the labrum, which will be used as a suture shuttle drill is used to create a bone socket for use with a labral SwiveLock. Now one can see that I've shuttled the LabralTape through the labrum, and I do this with a pulsing or gentle jerking maneuver. The tails are loaded through my labral SwiveLock. I leave a little bit of slack in the suture. To achieve the appropriate tension. One has to be careful when using LabralTape to avoid over tensioning, so I'll pass point well past my bone socket, then insert the anchor, avoiding over tensioning. The suture is cut flush with the articular surface of the glenoid. For our second anchor. We'll use a quick a QuickPass lasso to pass the suture shuttle through the labrum, bringing it up through the labral chondral junction. Here I'm using a single anterior portal technique, but certainly a two anterior portal technique can be utilized in the same manner. On this one, we'll demonstrate the use of a 2.9 biocomposite PushLock. Again, the drilling is on the face of the glenoid and not on the rim. The PushLock works similarly to a SwiveLock SwiveLock, but uses a pound in versus screw in technique. The tails are loaded through the 2.9 biocomposite PushLock. Again, I prefer to leave some slack in slack in the LabralTape by pass, pointing beyond the pilot hole, gently tapping the driver handle until the anchor body contacts the bone is a good way to introduce the proper tension as well. The suture is cut flush with the articular surface of the glenoid. Here, one can see that we've reestablished the height of the labrum, or reestablish the bumper effect and tension the capsule in the process. But we do not have to be concerned with possible knot migration. One of my biggest concerns or issues with traditional suture anchors is migration of the knot toward the articular surface. In many cases, I've seen well-placed sutures outside of the labrum have worked themselves back toward the articular surface and caused damage. This is among the reasons why I prefer Knotless fixation. Station. Now we'll place an additional PushLock, but in this case using a FiberStick. Again, I'll place the bone socket first. And again will be placed about a millimeter onto the edge. I find that above the equator establishing bumper height or lateral height is not as much of a concern. A FiberStick, which is a number two FiberWire with a stiffened portion that can be loaded directly into a QuickPass lasso, will pass directly through the tissue without a need for shuttling. This eliminates a step and can make our procedure more efficient. Once again, the anchor is positioned until it contacts the bone and articular cartilage. Orange clip is removed and then our final insertion is performed. The suture is cut flush with the articular surface of the glenoid. Here we can see how the anterior anteroinferior labrum has been addressed, but there's clearly a deficiency of the and tearing of the posterior labrum. And this creates a imbalance of the complex. And so we will add additional fixation posteriorly. Here we're placing a variant of a Wilmington port. I think it's important that this be placed medial to the cable, which corresponds to the muscle tendon junction of the rotator cuff and infraspinatus. Here we'll bring in a small metal cannula, and I want to use the small of cannula as possible. And I can bring in my Torpedo shaver through this cannula. And this can be used to debris, the glenoid as well as the labrum. This this portal. The Wilmington variant does allow for placement of an anchor as low as 7:00, and all the way up as high as 11:00 through this one posterior portal. Now we'll demonstrate usage of a PushLock with a FiberLink cinch stitch for my 7:00 anchor. I'll use a 90 degree QuickPass lasso percutaneous through the original posterior portal with no cannula. Note that I can pass a straight suture retriever through the metal cannula to grasp the suture shuttle, and subsequently the FiberWire. Fiberlink is a number two fiber wire with a loop on one end. This allows for an easy cinch stitch placement. I've loaded the loop of the FiberLink through the loop of the lasso. Now I feed the tail of the FiberLink through its loop to create the cinch stitch effect. It's easy to load the single FiberLink tail through the PushLock, and then the PushLock is brought into position and inserted as we've previously shown. This anchor is again placed at approximately the 7 or 730 position. This cinch stitch broadens the interface of the FiberWire and the soft tissue, which can be a weak area for any type of suture. Anchor fixation. A new mini suture cutter fits down the metal cannula and cuts sutures very flush with the articular surface. Again, I think it is critical to establish a balance to the complex. It's easy to visualize how the humeral head can sublux inferiorly if both aspects of the complex are not addressed. Now we'll pass one more PushLock to address the posterior aspect of the Slap lesion. We'll do this through the same portal we just used for the 7:00 anchor, and just can simply redirect up toward the 11:00. A FiberStick is again brought through a 90 degree lasso. There are several options for passing suture here. Very frequently I will pass this as a vertical mattress configuration, as Configuration as described by Neal Elattrache. But in this particular case, I feel that the tissue is rather weak, and I'd rather bring my suture around this labrum and sew. A simple suture configuration is utilized. Again, the anchor is placed at approximately the 11:00 position, somewhat onto the face of the glenoid. Although establishing bumper height or labral height in this, in this area of the labrum is not as essential as antero inferiorly. So here we can see a 360 degree repair with knotless fixation. I've been using Knotless fixation for nearly eight years with excellent results. I think this technique is quick and efficient, but more importantly produces the types of outcomes we're looking for in these athletes.

Jim Bradley, MD, (Pittsburgh, PA) discusses the incidence of first time anterior dislocators and the predictors of recurrence based upon their age, activity level, sport, sex, and injury. He describes the pathologic sequence of this injury including bony Bankart lesions, capsular deformation and elongation, Hill Sachs lesions, isolated capsular tear, and HAGL lesions and their effect on recurrent dislocation. He also shares his decision-making algorithm including non-operative management, contraindications, surgical intervention, patient selection criteria, and technique pearls.

First-Time Anterior Dislocators: What to Do and How to Do it

James Bradley, MD, (Pittsburgh, PA) performs an arthroscopic knotless SLAP repair on a 20-year-old overhead athlete with short 2.9 mm BioComposite™&nbsp;PushLocks&nbsp;and LabralTape.&nbsp; The LabralTape is utilized to secure the torn labrum with 37% greater tissue cut-through resistance than suture.&nbsp; Securing the LabralTape with the 2.9 mm PushLock results in a low profile knotless repair with no risks of knot impingement. &nbsp;

Arthroscopic SLAP Repair Utilizing LabralTape™ and 2.9 mm PushLock® Suture Anchors

I'm Doctor Jim Bradley from Pittsburgh, Pennsylvania. This is a case of a arthroscopic slap repair utilizing LabralTape and short two nine Biocomposite PushLock. This case is a 20 year old overhead athlete that had complaints of intra-articular pain and squeaking. Upon arthroscopic review, the superior labrum was torn and the previous suture was loose within the glenohumeral space. The inferior anchors and sutures were present and the initial repair was intact. The loose sutures were removed and the damaged labrum was elevated, and the bone was abraded with a Torpedo shaver for biologic repair. A five millimeter cannula was introduced with a sharp trocar into the joint space, and the most posterior portion of the labrum was repaired with a short two nine biocomposite PushLock with LabralTape. The LabralTape provides a low profile knotless repair while providing 37% greater tissue cut through resistance over number two suture. A second LabralTape is passed just posterior of the biceps with the SutureLasso and nitinol wire shuttle. The bone is drilled and another 2.9mm PushLock is inserted. It is essential to orient the suture cutter on top of the anchor to minimize the protruding suture tails. A third LabralTape is passed just anterior to the biceps with the SutureLasso and nitinol wire shuttle. The bone is drilled and the PushLock is inserted and impacted into the drill hole. The PushLock technique is very simple and certainly saves me time over tying knots with standard anchors. The final slap repair is complete with the LabralTape providing a low profile secure repair with no risk of not impingement.

The PushLock® is designed for simple and secure arthroscopic glenohumeral joint instability repair. The knotless technique saves valuable time and eliminates the possibility of knot impingement. The “Suture First” technique allows the surgeon to independently pass the suture through a desired amount of tissue prior to anchor implantation. Multiple suture configurations, including simple, cinch and mattress stitches, can be accomplished with FiberWire, FiberLink®, FiberStick or new <a href="http://www.arthrex.com/shoulder/labraltape" data-new-window="true" target="_blank" rel="noopener noreferrer">LabralTape</a> suture options using the Labral Scorpion™ or QuickPass SutureLasso™. Tissue tension can be visualized and adjusted, if necessary, prior to final anchor implantation.

A general overview including the relevant steps of an Arthrex surgical technique. These animations always include a voice-over explaining the process.

Eine allgemeine Übersicht, einschließlich der relevanten Schritte einer Arthrex Operationsanleitung. Diese Animationen enthalten immer Voice-Overs, die den Prozess erklären.

Operationstechnik-Animationen

Visão geral incluindo as etapas relevantes de uma técnica cirúrgica Arthrex. Essas animações sempre incluem uma narração explicando o processo.

Animações de técnicas cirúrgicas

Descripción general que incluye los pasos relevantes de una técnica quirúrgica de Arthrex. Estas animaciones siempre incluyen una voz en off que explica el proceso.

Animaciones de técnicas quirúrgicas

Surgical Technique Animations

PushLock® Knotless Instability Repair

The Arthrex PushLock is a knotless suture anchor designed for quick and secure shoulder instability repair. The PushLock utilizes a suture first technique that allows the surgeon to capture the proper amount of labrum and capsule prior to anchor insertion. The fiber wires are delivered into the bone socket. Tension is clearly visualized, adjusted, and then locked into position with the PushLock anchor body, creating a strong and low profile construct without knots. The suture first technique also allows the freedom for multiple stitch configurations like cinch stitch and mattress stitches. The Knotless PushLock saves steps and valuable time while providing a secure repair that eliminates issues with knot impingement.

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Knotless Instability Repair Utilizing Knotless SutureTak® and PushLock®

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