My name is Rick Ryu, and I have the privilege of sort of moderating this particular session. We are going to certainly thank Arthrex for sponsoring this non-CME surgical demo procedure, I should say. It's Eddie Echols. He's going to show us a rotator cuff repair using a speed bridge that's taking place at Florida Hospital, Carolwood, and we're very grateful to Arthrex, to the Florida Hospital, to Carolwood, and especially grateful to Dr. Echols, a very skilled surgeon, who's going to take us through this. And with that, if you have questions, you can come to the mic, and we'll make sure that the questions get passed on to Dr. Echols. So meant to be an interactive session, and at this point, I'd appreciate it if you can take us live, please. Dr. Echols, how are you? Yes, I'm doing well. How are you doing today? Great. So we have, you have a very, the audience is hanging on your every word, and so we're going to have you give us your take on the speed bridge for a rotator cuff repair, so take it away. Great. Thank you. Thank you. I hope everyone is enjoying the conference. And so, as Rick indicated, today we have a young man, I say young man, but we have an individual here that unfortunately sustained a rotator cuff tear. Just to kind of give you a little background, this is a gentleman that approximately six years ago sustained a bicep rupture, and apparently at that time, he was advised that he had some partial tearing to his cuff, but no surgery was indicated. I had the opportunity to see him approximately a month ago, where he gave a history of having been bowling, and in the process of throwing the ball, he felt a tear and acute pain. He came into the clinic to be evaluated. We worked him up, and he was noted to have a full thickness cuff tear, and he elected to proceed with the repair. So obviously, I've done a little work while you guys were not with me. We went through the glenohumeral joint, and as previously noted, his biceps is not present. He did have some fraying to his labrum that we debrided, and we were able to identify his cuff tear from within the joint, and we then moved into the subacromial space. What I'll do is I'll take you through a few of the portals, just so you can kind of see how I've worked through. Obviously, the posterior port is my viewing portal. Routinely, I make that approximately two centimeters inferior and medial to the posterior port of your acromion, and through there, I can go into the glenohumeral joint, and then into my subacromial space. This is my anterior portal, and through this portal, I can work in the glenohumeral joint anteriorly to debride tissue, do tinnitus, things of that nature, and then also, I can use this portal in my subacromial space as I do my repair, and you can see my cannula there. I also have my lateral portal that I used to perform my subacromial decompression. I went in, I cleared out the bursa, released the coracromial ligament, and I performed the acromioplasty, and then now, I have my superior lateral portal established. I have a cannula in this through which I intend to perform my repair. As we go into the joint, you can see here is my rotator cuff tear. I, once again, I've debrided everything and got everything prepped. I've freshened up the edges of the cuff tendon, and as a matter of fact, I'll show you I've got this mobilized. Can I have the cuff grasper, please? So, I made sure that the cuff was appropriately mobilized and ready for a repair, and as you can see, this comes over nicely. Okay, all right, let me take that back. Also, once again, I've de-corchated the greater tuberosity, which will help form a nice bleeding bed to help the cuff heal in place, and also, I cleared out all of the tissue that I had cleared out some of the bursa tissue over the greater tuberosity for our second row for our repair, and with that being said, we'll go ahead and start doing repair. What I'm going to do first is I'm going to place my medial row of anchors, and these will be directly off the articular margin, and then we'll use the suture pass, and we'll shuttle those sutures through the cuff tissue. Any questions at this point? No, this is terrific. Perfectly clear. Let's get started here. All right, so Mr. Corey, if you will take the camera now, all right, and let me grab that punch, all right, all right, all right, and this will be my anterior anchor. All right, back to you, Ms. Stacy, all right, and I'll now take that first anchor there. All right, all right, and let's do this. Let's let that clear. Yeah, take a picture there, all right, and now I'll take this tab off like so. Dr. Echols, can you describe the implant size and otherwise your punch? All right, so this is a 4.75 biocomposite, I'm sorry, squivel lock, all right, and so we made a hole with the punch appropriate for the size of the anchor, and now I'm going to screw this in. Good bone here. And are you loaded with suture or tape? So I am loaded with fiber tapes. These are fiber tapes that you can see in the shot here, and I'll put this back, all right, get that buried, all right, and now I'll pull this off, all right, and I'm going to remove this one suture, all right, and now I'm going to take my suture pass. I'm going to pass these sutures through my cuff defect here, all right, and I've got my cane, as I said before, positioned for retrieval. Let me get the Kingfisher. All right, we'll go ahead and park this. All right, great, all right, and I'll take the Scorpion, all right, got a good bleeding surface here, that's going to be good, all right, all right, and let's give me a little wash there, guys, all right, all right, all right, and let me play that a little bit there, all right, and so let's hold it again. I'm going to back this up a little bit, and so the key thing I try to do here is make sure I space out my sutures so that as I pull these over, I get a good repair on my cuff here, all right, and let's see here. I like that, so we'll bring that one up through, all right, hold that, Cory, all right. Miss Stacy, can you see? I'll tell you what, I'll grab it there. Let me see here. I can get this opened up. There you go, Cory, all right, let's do this. Take that for me there, and I'll grab this here. It came off. There it goes. So, Dr. Echols, I notice you're in the beach chair position. Do you mind my asking what is the minimum blood pressure you'll accept in this position? The minimum blood pressure, well, ultimately, I try not to go, Scorpion back, I try not to go below 100, so routinely, and that's really only if, say, for instance, I'm really experiencing significant bleeding, routinely, I'll run my pump at 35. Occasionally, I'll go up to 55 if need be, but by and large, I really won't harass my anesthesiologist unless I'm getting significant bleeding, and once again, at that point, I'll try to have them get the pressure down to 100 if need be, but never below 100. I don't request for that. Just to make sure we perfused the brain appropriately, all right. Now, we're going to pass this second switcher here. Can you see that, Ms. Stacy, this time? All right. Let me help you out there. All right, come in. You got it. Okay, let me come off. Hold on. All right, go ahead. Yep. There you go. Got it. All right, great. You can take that back, and so, as you can see now, we've passed the sutures through the, for that particular anchor, and we brought them out the top there, all right, and now, we get ready to pass, place our second anchor, so I'm going to rotate the arm forward a little bit so we can get posterior on our footprint, all right, and punch, all right, and mount, yep, and let's come over the top. Let's take a look, make sure we like where we are, and that second line is down. All right, great. Let's hold it right there. All right, back to you. All right, we're ready with second anchor. All right, anchor, there we go. All right, let's get a picture of that there. Great, all right, and let's do this. All right, and now, I'm going to take this off, make sure we have appropriately recessed the anchor. There we go, there, and now, you can take that back, Miss Stacey, and I'll take this off. I'll attempt to take it off. All right, there we go. You can take that, and let's pull this off. Great, all right, and now, once again, we're going to pass this next set of sutures through the cuff, all right, and once again, we'll go ahead. You can hemostat these, keep these out of the way. That's kind of a little bit of suture management outside of the portal, and now, we're going to go ahead and park the Kingfisher into that anterior portal. I like to retrieve my sutures out anteriorly just because it helps me with suture management. There is an instrument whereby you can go in, and the suture grasper will grab the suture and bring it back out the same portal, but for me, I like to kind of maneuver my sutures. Therefore, I can keep a clear field and retrieve the sutures easily. All right, let's see here, and then, and once again, I just kind of evaluate the cuff and try to space my sutures appropriately. Let's be good there. Hold on, let me come off. All right, go ahead, yep. So, Dr. Echols, for a double row like this and the concern we all have about over-tensioning a repair, what are you using right now to decide where you place these sutures in your cuff? All right, so what I'm using right now, obviously, I'm just kind of making sure that I've got a good spatial relationship so that as I bring the sutures over the bursal surface and insert my lateral row, that I've got good spacing on the cuff so I bring the tissue back to its native footprint. From the standpoint of over-tensioning, that's one of the reasons why I personally don't like tight knots immediately. I think that once I'm able to position the sutures through my lateral row and then tension them by hand, then I've got a good indication of how much pressure is being placed on the footprint and I can insert my second row of anchors. All right. All right, and then once again, I'll come up and make sure that I've got, all right, and can you get the mistakes here, all right, uh-oh, can you grab that, yes, I can grab it if need be. Let me help you out there, all right. All right, and so now, we passed all our sutures, and now we're going to start retrieving these sutures, and we're going to put in our lateral row of anchors, the loopy, and so at this step, then what I'll do is I'll retrieve a limb of each of my previous anchors, all right, so I'll take that one, and then I'll come up, yep, and I'll come up and I'll take, uh-huh, great, all right, and then what I'll do here, all right, this, I'm going to reposition the arm here, bring it up a little bit, and let me see here where we are, all right, and so now what I want to do is I want to kind of, hold that camera there for me, so I kind of pull a little tension and see how the repair comes down, make sure I like the position, and there you have it, I like that position there, all right, so where are we, we're right over here, all right, so I'm going to bring this up a little bit more, like so, all right, and once again, we'll look here, so I think I'm liking that position, and I'll just kind of put a little tension on these sutures to make sure everything comes over, all right, great, all right, so I like that, all right, and now hand me the, okay, let's do this, let's attach the anchor to the sutures here. There you go. We'll stat those. Great. All right. And now, once again, we like our position here. All right. And so, let's take, you got that, Corey? Let's take the punch. All right. Let's go in. There we go. I like that right there. All right. And obviously, with this particular anchor, they have the lines demarcated on the punch for the attendant anchor that we're using. The SL obviously stands for split block in this instance. All right. So, now, the next thing I'm going to do is have me hold that up. You'll hold that up taunt so I can basically kind of slide that anchor in place once I remove this punch. Is it the same size anchor, Dr. Echols? Yes. I use 4.75s both medially and laterally. That way, like I said, I abide by the KISS principle, Rick. You know, the keep it simple, stupid. Fool. Okay. All right. All right. There we go. And now, what we're going to do is, you can take that. And I'm going to tension these a little bit before I seat this. All right. Let's come up and take a look up here. Make sure we like what we got. All right. Good. All right. And now, Ms. Stace, if I can get the mallet. Tell you what, let's do this here. Did I screw it down? Yeah. Let me put this in. I'm sorry. Tap that in a little bit. All right. Let's get a picture there. All right. Let's get this in place. And we're going to go ahead and load this up on the cutter. All right. Great. You'll take that. All right. You can take it over there. All right. And now, I'm going to slide this cutter down. We're going to cut our sutures here. Great. All right. You can take that back. All right. And now, what we'll do is, we're going to rotate around here. Let's look up here. See where we are. We got a few strands hanging on there. Let's see here. All right. And make sure we like what we got. All right. I'm going to bring this up a little bit, like so. All right. Now, once again, let's come up. We're going to retrieve our sutures. Lupe? All right, and then we'll come over and get our next one. All right, and then once again, you can take that. Now we'll back out and we'll attach those sutures to the anchor there. All right, and then once again, I'll kind of bring this down and make sure we like what we're getting. Yes, I like the way that's coming together. All right, great. And so, now what we'll do is we'll go right there. All right, so let me get that punch. All right, mallet. All right, back to you. All right, so once again, I'm going to stay in this, and what you're going to do is you're going to hold that taunt so that I can slide the anchor right there. You can grab the sutures here if you want. All right, and I'm going to take these out. Pull, pull on those sutures, pull, there you go. All right, and there we go, great. And so, thank you. And so it helps what I do, and I don't know if you're able to catch it on the screen, but I had my tech basically just kind of hold the sutures taunt, so that way I can just kind of slide the anchor down the sutures, really without having to remove my eyes from the field. That helps. Sometimes if you've got a really bloody case or something like that, and you take your eyes off the field, then you can lose where you are. So, can you hold that for me there, of course? All right, and now, mallet. Let's get a picture there. And Miss Stacy, if you'd be so kind as to lower the cutter on there. And there's one central suture that I'm taking out. Sometimes if you feel that you need some extra fixation, you can use that to help tie down a dog ear or something like that. Routinely, I don't end up having to use that, but that's an option. All right, thank you. All right. And we'll come down and we'll cut it. All right. All right. That's back to you. And let's take a look-see here. And there we have it. And we've got our cut prepared. All right. And let's bring it around here. And that's going to be anteriorly. And as I let this down. And there we have it, guys. Any questions? You know, Dr. Eggers, that's terrific and thank you. That was masterful and we all appreciate that. I think we have time for a couple of questions, if you don't mind. Sure. So one that I want to ask you in the audience, please, if you have questions, there's a big question about the need for a medial tie down or not, or whether it's suture or fiber tape or what have you. How do you feel about that medial row? And let's say you did this with suture and not suture tape, does it make a difference? Well, once again, no. Some people will use, they'll tie knots at the medial row. Once again, I personally don't want, sometimes depending on how tightly you tie those knots, you could potentially kind of start to over tension the graft. I think that by using the suture tape in my hands, I get good dexterity. I can kind of feel how tight I'm making the repair. And therefore, I can get by without tying it down. But that obviously is an option. And that is a technique that some employ. Okay. Can I ask a little bit of post-op, again, terrific example of a speed bridge and thank you for that. What about your post-op protocol? What position do you hold them in and for how long? Okay. So, and I think I may tend to be on a little more of the conservative side, but my thought is that I would prefer to go slow and have the patient progress steadily as opposed to potentially go too fast and have a recurrent tear or setback. So, that being said, initially today, I will put this individual in a sling with an abduction pillow and I will have them wear the sling and the abduction pillow for four weeks. At the four-week mark, I bring them out of the pillow and just have them wear the sling for an additional two weeks. So therefore, they're immobilized in some fashion for six weeks, which I feel is going to be that initial point of healing, which allow the cuff to establish to the footprint. Now, during that period of time, however, I start therapy when they come back for their post-op visit, which is about 10 to 14 days from now. And at that point, they'll start therapy and we're doing the passive phase of rehab. So passively, we're moving the shoulder within a certain range of motion during those first six weeks. At the end of that six-week period, I'll then bring them out of the sling and I'll progress them to the active-assisted phase, which they'll do for like another six weeks or so. And then finally, at the three-month post-op mark, I'll progress them to the strengthening phase. And for a tear like this, which was relatively non-retracted, do you do the same protocol for let's say a larger retracted tear? So okay. So if I have a very large retracted tear or a tear where I'm concerned about the soft tissue and the strength, then in that instance, I will hold those individuals still. A lot of times, I may not start therapy right away. I will... And one thing I didn't say is that while they're in the sling and pillow, I have them do elbow and wrist range of motion exercises. So if I have an individual that I'm concerned about the quality of their tissue or disrupting my repair, then I won't start therapy. I won't start therapy during that first six weeks. I'll just hold them still and just have them do elbow and wrist range of motion exercises and then initiate therapy at the six-week post-op mark. Yeah. I think that that's sort of the consensus now for the very large difficult tears to be much more conservative about holding off on early motion. Can I ask you about the anti-inflammatories? Do you allow them anti-inflammatories? As a matter of fact, I do not. Routinely, I instruct my patients not to take anti-inflammatories during the first six weeks primarily because I feel that the first phase of healing on the cellular level is the inflammatory phase. And so in that instance, I don't want to thwart the healing response. So I'll hold them off of the anti-inflammatories in the first six weeks. I'll have them take either Tylenol or their pain medication. Great. Are there any questions from the audience? This is, again, Dr. Echols, a masterful, it looks terrific and we thank you for your expertise and we thank Arthrex and Hollywood, I'm sorry, Florida, I'm sorry, Florida Hospital in Carolwood. Thank you for entertaining this and again Arthrex for sponsoring it. Are there any questions from the audience for Dr. Echols to the procedure that you saw? Anything? I'm sorry. We have a question coming up, Dr. Echols. Sure. We're keeping your patient under anesthesia for a little while longer here. Hang on. Go ahead. Thanks, Dr. Echols. That was a great repair. But I like to keep it simple too and I'm still a single roll guy. The second, this is the second surgery I've seen with double rows on relatively smaller non-retracted tears. Is there still a role for single roll repair? I would tell you that, you know, okay, so in this instance, this was a, I'd say minimally retracted but it was a decent sized tear. Routinely for me, if I had a completely say non-retracted tear that was small, in that instance I may be inclined more so to do just a single roll. But ultimately, as you know, as far as healing goes, you know, we think we do a great job and then sometimes we still have failures. So if in fact the tear is of a larger size or is retracted at all, then routinely I'll do a double roll. But once again, if it's very small and not retracted at all, then that'd be an indication for me to do a single roll. Thank you. Great. Thank you. You know, there are very few surgeons who can tackle live surgery and live surgery would do it very, very well. So Dr. Echols, thank you. It's been terrific. Thank you, Arthrex, for sponsoring this event. Thank you guys for having me. I hope you enjoy the rest of your conference.

Dr. Eddie Echols

rotator cuff repair

speed bridge

surgical demo procedure

Florida Hospital Carolwood

Arthrex