The Knotless 1.8 FiberTak® soft anchor and PushLock®&nbsp;anchor are knotless suture anchors designed for arthroscopic glenohumeral joint instability repair. The Knotless 1.8 FiberTak soft anchor is inserted through a guide. The suture is first passed through the labrum and then through the locking mechanism, before it is 
sequentially tensioned to create a low-profile knotless repair. The PushLock anchor enables independent suture passage through the desired amount of tissue before anchor implantation, allowing for proper visualization and adjustment of tissue tension prior to final implant insertion.
Please note that certain bio (PLLA) anchors and screws are not available for sale in EMEA.

Shoulder

Procedure

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.

E. Lyle Cain Jr, MD, (Birmingham, AL) discusses arthroscopic posterior instability and SLAP repair by presenting a case study of glenohumeral instability on a collegiate gymnast. Dr. Cain discusses the use of simple and mattress stitches with the unique adjustability of the Knotless 1.8 FiberTak® suture anchors to achieve an anatomically tensioned soft-tissue glenohumeral labral repair.

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Human

Tensionable Knotless Posterior Instability and SLAP Repair Using the Knotless 1.8 FiberTak® Soft Anchor

Hi, I'm Lyle Cain. I'm going to show you a technique today using alternating mattress and simple sutures for labor repair using the 1.8mm knotless FiberTak anchor. This first case is a 22 year old female collegiate one division gymnast at elite level, who has had two years of posterior shoulder instability. She was able to compete with us, get through competition with some modifications. She took off from bars in certain events, but had a recent injury which resulted in bicep tendon subluxation and a slap tear. On physical examination, she had obvious posture, shoulder instability with apprehension, labral grind and labral signs. She also had bicep tendon pain and popping and some mechanical symptoms for her bicep tendon with a dislocated bicep tendon. Mri scans showed a posterior labral tear, a slap lesion and biceps tendon dislocation out of the bicipital groove. The plan for her surgery was to do an arthroscopic posterolateral repair, a slap repair and a sub pectoral biceps tenodesis for the biceps tendon dislocation. For the surgical technique, we have several pearls. I think it's much easier to prepare the posterior glenoid from the anterior portal. So in this particular case, I'm case. I'm looking through a visualization. Through an accessory. Posterior. Viewing portal. The shaver is coming through the anterior soft spot or rotator interval portal. And that's the easiest way to prepare the posterior infraglenoid. Initially, we place a 1.8 knotless FiberTak anchor through the accessory posterior portal while visualizing anterior. I like to do a mattress suture along the lowest portion of the labral tear. This has several benefits. It reduces the capsular tissue to the labral neck. It prevents the labrum from rolling off the glenoid when you release traction, and provides for nice fixation up against the bony bed. This FiberTak anchor has a nice configuration, where the shuttle stitch has a round end and a flat end. The round end indicates the loop portion of the suture which we use for passage of the repair stitch. So after we pass the repair stitch through the label tissue, we grab the rounded loop suture, pull it out the portal with the repair stitch, and then shuttle the suture through the anchor for the final knotless repair. As I continue up the glenoid from inferior to superior, I like to alternate sutures using a mattress suture low, followed by a simple suture, followed by MaxForce suture followed by simple suture. This allows for maximum fixation and tissue compression along the glenoid neck, with the mattress suture and maximum labral bumper for the simple suture. If you look at these simple sutures critically as you release tension from the shoulder, oftentimes the simple suture allows the labrum to roll off the glenoid and roll down the glenoid neck. The mattress suture will prevent this. This knotless mechanism, as you will see, allows maximum tensioning. You can put as much tension as the tissue can tolerate. For older patient population with worse tissue quality, we pull on the suture less and do less tension for these young athletes. The 22 year old gymnast. We're able to put a lot of tension on this labrum and really get a good labral reduction. The last thing I like to do is a posterior capsular closure on all of my unidirectional posterior instability cases. I think preventing capsular laxity, venting the capsule, we know in the hip and other joints that having a capsular hole causes some instability in certain cases. So I use the SutureLasso to pass the suture through the posterior portal and close my portal prior to closure. The next portion of the case included the slap repair. In this particular case because of her biceps instability. We had performed a biceps tenotomy for later pectoral tenodesis. The curved FiberTak drill guide makes it nice that you can get a posterior superior slap portal and anchor placement out of the Anterior-superior soft spot portal. The curved guide allows you to get the angle properly, so that you can put these anchors in without going through the rotator cuff. So we'll put the anchor at about the 11:00 position. It's passed through the labrum just behind the biceps insertion, and passed in a simple configuration using the knotless mechanism to tie down the labrum. As you can see, we get a nice superior labor repair in terms of final repair. As you'll see, we have a mattress stitch at the lowest portion of the repair, followed by a simple stitch that rolls the labrum up and forms a nice bumper. This alternating configuration allows for restoration of the bumper, maximum compression of labral tissue against the glenoid neck for better healing, and ligament tension reestablished by the ligament being pulled back to the glenoid neck. In terms of results, we have implanted over 4000 FiberTak anchors in Birmingham at the American Sports Medicine Institute. Just over the last four months alone, we've implanted over 400 of the Knotless 1.8mm FiberTak anchors. Overall, we've seen excellent anchor performance. It's a nice 1.8mm small drill guide and hole that allows for many points of fixation for these difficult labral tears. It allows less bone removal, which we feel gives you less risk for glenoid rim fracture in the future. The anchor deployment is very reliable and functions in all types of bone quality. It's easy Knotless mechanism allows for individual tensioning, so for the large labrum tissue and the athletes, you can really tighten this thing down and get good hard fixation. It gives you a strong, low profile cordless FiberTak repair with no knots for no potential damage to tissue from the knot placement. It allows for knotless suture to be placed in a mattress or simple stitch configuration, as we've shown in this video, and eventually gives you the same, or maybe even better repair in a final repair than the traditional knot tying. But you have less surgical time and without the knots, and so you have a lower profile configuration. So overall, this is an excellent repair technique. I like the mattress and simple stitch alternating because of the healing response as well as the bumper that you restore. And I think you'll be happy with this repair.

Case Presentation: What Your Knots Are Doing To The Rotator Cuff

I'm actually going to show a brief case of demonstration to what suture material, especially the very strong non-absorbable suture material, can do inside the shoulder to both the cuff. And also, I've seen significant abrasive changes on the articular cartilage in the glenohumeral joint. So this is a 19 year old female left hand dominant. And. That top line is wrong. She's a right hand dominant hitter college volleyball player. And she had presented with a two year history of posterior left lateral shoulder pain following arthroscopic labral repair that she had performed. She was unable to return to to college volleyball without pain, despite aggressive rehabilitation, and she complained of posterior lateral shoulder pain and a dead arm when swinging. She had had the surgery performed prior to her presentation to me in May of 2008. She had had a superior labor repair in a vasectomy, and the rotator cuff was noted to be, quote, normal with no articular sided abrasion or tear. On her physical examination, when I saw her, she had generalized hyper laxity, as we see with a lot of these volleyball players. She had apprehension. She had a positive relocation sign. O'brien's test was positive in all of her impingement signs were positive. She had negative sub scap signs and no pain with crossover. Further exam showed the Paris Scapular dyskinesias with mild winging. So she had a sort of a protective scapular dyskinesias that she was using to keep her out of pain. She had good strength of her rotator cuff. Mild tenderness to palpation over the bicipital groove. Mri scan findings showed some supraspinatus tendinosis with partial articular sided cuff tearing. She had cystic formation at the anterior margin of the distal supraspinatus. Mild separation of the anterior-superior labrum and a patulous capsule. You can see here the cystic change in the anterior aspect of the greater tuberosity, just behind the biceps. So I took her to the O.R. in July of 2010. And we're going to see the what we found. We saw the labral repair itself had healed, but there was this not that then with with in the in the overhead hitting position or would be in the throwing position that not has abraded braided and cut a hole in the side of the rotator cuff. So, you know, even before this case, I'd become very concerned with what these knots can do in that particular kind of patient. When they get up here, the rotator cuff is going to drape itself over the posterior superior glenoid rim and labrum. And so not material is not as as benign as what we might think. And while a lot of times it does get covered over with synovial tissue or scar tissue in the back there, sometimes the these knots are very prominent. And with constant abutment and abrasion, you'll rub off that biologic layer that forms. And these these braided nylon knots are sitting right there. And do abrade the, the rotator cuff. So this is not the first time I've seen this. And it certainly causes symptoms in a lot of cases. So I took that knot out. We repaired the anterior-superior labrum because the part in front of the bicep was off, and that's why she was getting apprehension. So she actually felt the shoulders slide a bit and the anterior-superior labrum had had to be repaired. I took that posterosuperior not out at six months. She's got good range of motion nine months. She returned to volleyball at the end of her college eligibility. So she was able to salvage that last year of college. But but it's loss of time in somebody like this is can be a devastating problem for these college athletes. And your high school athletes have a certain amount of time to get back. So something is benign as as not problems on the undersurface of the cuff can cost them a season which which for them is very meaningful. I'll refer to this again in my my next talk on superior labor repairs, where I show a knotless technique for repair. Thank you.

This animation provides an overview of the features and benefits of the Knotless 1.8 FiberTak® soft anchor for the treatment of shoulder instability.

Knotless 1.8 FiberTak® Soft Anchor for Shoulder Instability Repair

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Knotless 1.8 FiberTak® Soft Anchor for Glenoid Labrum Repair

Knotless FiberTak® Soft Anchor Technique - SLAP

Child (D)

The PushLock anchor is designed for simple and secure arthroscopic glenohumeral joint instability repair. The knotless technique saves valuable time and eliminates the possibility of knot impingement. This suture-first technique allows surgeons to independently pass suture through the desired amount of tissue before anchor implantation. Multiple suture configurations, including simple cinch and mattress stitches, can be accomplished with FiberWire®, FiberLink®&nbsp;SutureTape, FiberStick™, SutureTape, or LabralTape™ sutures using the Labral Scorpion™ or QuickPass™ SutureLasso™ suture passers. Tissue tension can be visualized and adjusted, if necessary, prior to final anchor implantation.
Please note that certain bio (PLLA) anchors and screws are not available for sale in EMEA.

Paul C. Brady, MD (Knoxville, TN), performs a cadaveric SLAP repair using PushLock® suture anchors and FiberStick™ SutureTape. Dr. Brady demonstrates how to use FiberStick SutureTape in a simple and mattress configuration.

SLAP Repair Using FiberStick™ SutureTape With 2.9 mm Short PushLock® Anchors

Hi, my name is Doctor Paul Brady. I'm from Knoxville, Tennessee. Today I'm going to be demonstrating a slap repair utilizing a suture tape fiber stick as well as a short two nine push lock anchor. So for suture passage I chose to use a suture lasso device. This is a right sided curve for this left slap repair. So we'll work through our anterior superior lateral portal. I think that'll give us the best view. We can go underneath the biceps, but I think I'll go over the biceps. I think it'll be a little bit easier. And we'll get a good bite of the labral tissue, trying not to get the capsular tissue behind it, because we don't want to cause too much stiffness. We'll penetrate that and just give it a little roll and a little wiggle. And then once we have it there, we'll roll that in. I'll roll a good amount in and then we'll reach with a fully toothed grasper from my low anterior portal. So the stiff portion of this suture tape fiber stick implant has a monofilament inside of it. So when you grab it, you don't have to worry about it. Abrading the suture and causing damage to the suture. Well, even those two ends up relatively close. Now our repair suture is in a good position. Now we'll create a bone socket to secure those repair sutures within, drill our hole in the bone. So I'm using the mini kingfisher retriever. And I'm going to pull both of those sutures up through my port of Wilmington. I like to cut off the monofilament stiff portion of the suture, because it loads easier into the anchor eyelet if you don't have to deal with that stiff portion of the suture. So we'll load our repair sutures into the eyelet of the anchor. Slide that down and give it just a little bit of tensioning here. Slide that down. And once the anchor is down onto the bone, we'll remove the protective covering. And then we'll secure that down, turn this counterclockwise to unload it from the eyelet, and we'll just put this right on top of the bone and cut that flush with the bone. So here you can see how that suture tape gives you that nice broad area of compression of your tissue onto the bone bed. Let's go ahead and pass our second suture in a horizontal or an oblique configuration. Again we'll come over top of the biceps. We'll take our first bite just behind the root of the biceps here trying not to get this capsule. And penetrate and then just turn. And then we'll grab that here. And I'm just going to hold that for a second and I'm going to pull this back. We'll feed a little bit of slack in this suture. And then we'll penetrate right about here. So my assistant is holding that first pass, and then I'm going to grab the second pass and hold that while we unload the device. All right. So now you can see we've passed this in a horizontal mattress fashion. You have that nice broad compression that the suture tape gives you. And those sutures currently are coming out of our low anterior portal. I'll use the mini kingfisher to pull those out my anterior lateral portal again, to pass these easier through the eyelet of the anchor, I'm going to go ahead and remove the rigid portion of the suture and get to the suture tape portion of the suture. Then I'll even those ends up, and we'll be ready to insert those into a bone socket. So we'll go ahead and create our bone socket again through our anterior superior lateral portal. This is a good insertion angle I believe. So we'll put it right underneath the root of the biceps. And then go ahead and drill that. A small trick for loading these sutures into this eyelet is to double over the sutures, and that makes it easier to load into the flag. We'll go ahead and compress that into our bone socket. Secure our anchor and then turn counterclockwise to unload the inserter from the eyelet. We'll load those sutures into a mini suture cutter utilizing the mega loader, and put that right down against the bone. So there we have our completed two anchor repair of a superior labral tear with posterior extension. Posterior anchor utilizing the suture tape fiber-optic implant into a 2.9mm short push lock anchor site. Second is an oblique mattress. You see that nice broad compression that that suture tape gives you into? Again, another short 2.9mm push lock anchor site.

Elbow

Imaging and Resection

Kyle Anderson, MD, (Detroit, MI) explains that a knotless approach can be very beneficial to overhead athletes and performs a knotless, posterior SLAP repair through a small, percutaneous metal cannula. Dr. Anderson creates a mattress stitch by passing a FiberStick™ (stiffened #2 FiberWire®) suture directly through a SutureLasso™ suture passer. He also highlights use of the Torpedo™ shaver for a quick and clean labral and glenoid preparation.

Knotless SLAP Repair Using the Short 2.9 mm BioComposite PushLock® Anchor

Here we have a 25 year old male right shoulder who has evidence on his examination and imaging of a type two Slap lesion. I'm using a Torpedo shaver to breed the superior labrum. It's also excellent for debriding. The glenoid below the labrum nicely removes degenerative and torn tissue and freshens the superior glenoid bone. The Torpedo tip makes it nice for dissecting underneath the labrum, even posteriorly from an anterior portal. Here, while I'm viewing from an anterior portal, I'm going to pass through a Wilmington variant portal, a small metal cannula which is only an outer diameter of 5.5mm. First, I localize this by passing a spinal needle. I want to make sure that the portal is past medial to the cable or muscle tendon junction of the rotator cuff. In this particular case, there is some fraying of the underside of the infraspinatus. This can be debrided with the Torpedo shaver. I can bring in the Torpedo shaver through the metal cannula. Here the drill is brought through the small metal cannula and used to place a pilot hole at approximately the 11:00 position. Many surgeons prefer to pass suture prior to drilling of the bone socket. I prefer to drill the bone socket first, which allows me to position the anchor relative to other anchors, and I can match the position of the bone socket with passage of my suture. Fiberstick is a number two FiberWire with a stiffened portion that can be loaded directly into a QuickPass lasso and will pass directly through the tissue with without need for suture shuttling or a nitinol wire. In passing a vertical mattress suture, I take a somewhat more medial bite of the labrum posterosuperior early, and retrieve the FiberStick tail through the metal cannula. Then I back the lasso up without removing it from the joint, keeping it within the capsule, and then simply pass through a second time, this time closer to the edge of the labrum. The vertical mattress suture creates a very low profile fixation and nicely opposes the posterosuperior labrum onto the glenoid. Here we're going to use a short 2.9 biocomposite PushLock for our suture anchor. This short PushLock is three millimeters shorter than the standard version, which minimizes bone removal and the amount of anchor material that's implanted. The anchor is brought into contact with the glenoid, then the orange clip is removed, and then the final advancement of the knotless anchor is performed. Here I use the special mini FiberWire cutter that fits through the small metal cannula. This creates a quick and low profile superior labral repair with essentially percutaneous technique, which I feel is especially important in throwing an overhead. Athletes.

PushLock® Suture Anchor for Knotless Instability Repair

PushLock® Mattress Stitch SLAP Repair

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.

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.

SLAP Repair

Knotless FiberTak® Soft Anchor Technique - SLAP

PushLock® Anchor Technique - SLAP