diet guy and try to stay away from pasta whenever possible and for all you guys in the back there's plenty of seats up in the front aside from Dr. Kelly none of us bite so you're welcome to take these seats. My disclosures are also available in the program and on the website. So I've been asked to address suture spaghetti and dealing with tangled sutures and whether you're doing single row or double row it's kind of like different shapes of pasta they can all get tangled and you still have to be ready to deal with it when it happens. Suture management today still remains one of the great challenges we face and whether we're doing single row or double row or a trans osseous equivalent you're still faced with how to manage these sutures and do it effectively because when your sutures do get tangled it's incredibly frustrating it adds stress to you, your PA, your assistant, your fellows and it's one of those things you want to try to avoid. Despite the time and anxiety we have to figure out how to deal with this and my best advice for you today is just don't tangle them in the first place be very diligent and have a reproducible technique to avoid ending up with suture spaghetti intraoperatively. I think the techniques are going to differ whether you're approaching this as a single row or double row and from a double row point of view I think it's easier suture management because today we're making fewer passes through that tendon right particularly with a tape based approach where you may be just only making two poke holes through the rotator cuff. In those cases with a double row technique I would tend to approach it with a posterolateral viewing portal and then use an anti-grade suture passer coming in from the lateral portal that has a self-capturing device and with the newer techniques you can use double loaded tapes through a single pass that you can then make only two passes potentially for an average size rotator cuff tear. What you then want to do is store that pass suture out in an alternative cannula so if you're looking from posterolaterally you then store your sutures anterior-loposterally and then repeat that process with your anti-grade suture passer through the second device and you're going to really reduce your risk of getting suture spaghetti. I think the bigger risk with these trans-osseous equivalent approaches though are really the lateral row and getting your lateral row in. Not so much suture spaghetti but lack of visualization. So you want to spend the time before you begin passing your sutures to debride that lateral bursal shelf and you can increase the abduction as needed to give you better visualization, better positioning so that you know where your lateral row anchor is going to go. You then want to just retrieve your sutures or your tapes just before you're loading that lateral anchor so that you're not going to get anything tangled. With single row repairs I think there is still a significant role for this technique and it seems like we've thrown away the baby with the bathwater and it matters whether you're using double loaded versus triple loaded anchors when we're doing it. Three sutures certainly add strength to your repair but it also adds significant complexity and increases your risk for tangling and getting that suture spaghetti. So I think you have to be careful as you're doing this. For me I tend to use triple loaded anchors exclusively. So for an average size tear, two anchors, six passes through the rotator cuff. For a bigger tear it may be nine passes through the tuck and you then have to be ready to address the partner stitch or you're guaranteeing yourself not only spaghetti but angel hair and it's going to be a mess. So in these cases I use a different technique versus a double row technique. I tend to prefer direct lateral viewing and I am able to then well they're easily manage my sutures. All the anchor companies today offer multicolored sutures which do assist us when you have multiple tails but in these cases I prefer to do retrograde passing using a shuttling system so that each individual pass is retrieved out an alternative cannula so it's out of my way. As I call it parking the stitches so I don't have to deal with it. So in this case I'm looking directly from lateral I've passed the post suture and then I'll retrieve its partner stitch out the posterior cannula take these outside the cannula so I don't have to worry about them as I move on to my next pass which would be the green and white. In this case we avoid the suture tangling and suture spaghetti. There are some proprietary devices that are available and we use these little color-coded straws that you can then pass on the individual pair and if I'm doing a three anchor cuff or I'm doing now something that's going to require a dermal allograft augmentation or an SCR I'll oftentimes use these little straws to help protect me. They're a bit time-consuming but they help. For a more average size tear I use what I call a pass and park technique where I'll pass all three posts first and then I'll come in and retrieve all of their partner stitches at the same time after I've completed my retrograde passing. It makes it easier and then I can go ahead and store those outside the cannula and move on to my next anchor. I'll follow that same suture pattern for each anchor so if I go blue, purple, braided blue, I stay with that the whole way through. Then you just move on to suture tying. I'll move the scope either the anterior or posterior portal and tie the individual pairs. In general I tend to make all my passes from posterior to anterior and then I tie back anterior to posterior so I avoid suture tangling. If the sutures do become tangling we have a couple of options. You can use a crochet hook to come in here, move the tangled sutures and come in and retrieve the partner stitch, take those two sutures out that alternative cannula. Use your docking cannulas there for a reason and then you can pull up on the other sutures and it should eliminate that tangling and that's a good option for us to use. If it's more complex I'll bring in a knot tire down an alternative cannula to deliver that suture. So you can see here I want the wide braided blue and white stitches. I don't want to tangle that narrow blue white suture so I'll come in and retrieve it and make sure I'm going to stay anterior to that narrow braided blue suture so that I'm not going to get tangled and once I've now retrieved those out my lateral cannula I'm ready to go ahead and tie. So there's lots of options available as we think about this. So in the first place please just don't let it occur. Go keto friendly. Thorough debridement will allow the visualization you need and if you use alternative docking positions with either inside or outside the cannulas you'll be okay and make sure you don't unload your anchor as you're doing this. You can either use a suture retriever to isolate the pairs or run the knot tire in and that should allow you to be successful. Thank you very much.

suture management

surgical procedures

suturing techniques

tangling prevention

suture untangling