anchors, sutures, knots? my technique for arthroscopic...
TRANSCRIPT
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EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Anchors, Sutures, Knots? My Technique for Arthroscopic
Stabilization
R O B E RT N A S C I M E N TO , M D, M S
C H I E F O F S P O RT S M E D I C I N E & S H O U L D E R S U RG E RY
N E W TO N - W E L L ES L E Y H O S P I TA L
M E D I C A L D I R EC TO R & H EA D T EA M P H YS I C I A N , B O STO N C O L L EG E AT H L E T I C S
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EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Disclosures
Depuy Mitek Sports Medicine – Speaker / Education
Smith & Nephew - Consultant
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EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Technique
Positioning◦ Lateral decubitus vs beach chair
Repair configuration
Number/type of suture anchors
My technique for anterior stabilization
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EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
The great debate . . .
Does positioning in the OR play a role?
“Arthroscopic” vs “Shoulder” surgeons
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EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Systematic Review of Outcomes Between Beach Chair and Lateral Decubitus
64 studies included from 1990 – 2013 minimum of 2 year follow up
Recurrent instability rates:◦ Beach Chair = 14.65% +/- 8.4%
◦ Lateral Decubitus = 8.5% =/- 7.1%
Average Loss of ER:◦ Beach Chair = 2.4 +/- 1.0 degrees
◦ Lateral Decubitus = 3.6 +/- 2.6 degrees
Frank, Arthroscopy 2014
P > .05
P = .002
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EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Repair Biomechanics
Single row vs Double row Repair?◦ Biomechanical advantage
◦ Increased load to failure
◦ Significantly increased labral footprint coverage with DR repair◦ Single 32-42% vs Double 73-86% Amhad JSES 2009
Kim AJSM 2011MacDonald Arthroscopy 2016
MacDonald Arthroscopy 2016
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EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Repair Biomechanics
Difference in footprint coverage in DR vs SR repairs◦ DR: ~75%, SR simple knots: 38%, SR horizontal: 33%
No difference between suture and tape
No difference between load to failure, stiffness, or cyclic displacement of SR vs DR repair
2017
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EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Single vs Double Loaded Anchors
Nho et al, AJSM 2010◦ 2 DSA vs 2 SSA◦ No difference in SSA vs DSA in all biomechanical testing
Kamath et al, AJSM 2013◦ 2 DSA vs 3 SSA◦ DSA with increased ultimate tensile strengh◦ No difference in displacement at failure, load at 2mm
displacement, stiffness, energy at failure
Limited data would suggest:
No significant difference in SSA vs DSA
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EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Knots vs Knotless?
Leedle Arthroscopy 2005◦ Knotless biomechanically stronger than knotted
Slabaugh Arthroscopy 2009◦ No significant difference in labral height
Hanypsiak AJSM 2014◦ Skilled surgeons do not tie knots consistently◦ Surgeons <10 yr from training tied stronger, more consistent knots◦ Surgeons >200 shoulder cases a year no better than those with less cases
Kocaoglu KSSTA 2009 ◦ No differences in outcomes between knotted or knotless
Ng and Kumar Arthroscopy 2014 ◦ Level II study◦ No differences in outcomes between knotted or knotless
Bents Am J Orthop 2017 ◦ No differences in outcomes between knotted or knotless
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EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
“Lastly, the number of suture-anchors was critical: patients with three anchors or fewer were at higher risk for recurrent instability (p = 0.03). “
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EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Portal Placement
Posterior
Anterior - Superior
Anterior – Inferior
Posterior – Inferior
(7 O’clock)
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EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Anchor Placement
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EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Evaluate the lesion
Verify little if any bone loss
Complete release from the glenoid
Goal to have a balanced repair
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EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Elevate
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EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Complete release
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EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Repair
Start with a 7 o’clock anchor
Then march up from 5:30 employing a proper capsulorraphy effect from inferior to superior
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EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
7 o’clock anchor
Right shoulder posterior viewing portal
Left shoulder anterior superior viewing portal
7
4
56
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EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Capsulorraphy
Typically about 1cm
Beware in patients with hyperlaxity and the very young
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EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
March up the glenoid
5:30 anchor is double loaded ◦ Typically 1 horizontal
and 1 vertical stitch
Use of a “luggage tag” suture for knotless anchors
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EVALUATION & TREATMENT OF THE INJURED ATHLETEADVANCED TOPICS IN SURGERY AND REHABILITATION
Thank you