I'd like to welcome everybody to this live surgery demonstration. Dr. Mark Mile is going to be the surgeon, and we have a rotator cuff repair. I'd like to remind everybody that this is a sponsored program by DePue MyTech, and consequently there's no CME associated with it. And if anybody has a question that they'd like to have posed to Dr. Mile, come to one of the microphones and wave at us. I'd like to introduce our co-host, Peter Bronson from Liverpool, England. Peter. So, it's a pleasure to be here. I clearly must have some relatively good characteristics because John invited me as a British person, and I have no Irish roots at all, but I'm counting that in my favor. Shall I run through the case? Dr. Mile, would you like to introduce your team? Yeah, I'll introduce my team. It's Mark Mile, I'm in Tampa. I got my UVA hat on, UVA national champions, and I want to thank John Kelly, my favorite Irishman. I want to let John Kelly know I did a little Ancestry.com, and apparently my great grandfather married a Gleason. So, from Cork County. So, I'm pretty happy about that. So, I got a little Irish in me. I got Kim Franke, she's my fellow. She's from Montana. She's awesome. And then we have Stacey, who's been my tech for a long time wearing her Cubs hat. We got Mike in the back working our water. We got Karen doing our anesthesia, keeping the patient doing wonderful. And then we have a wonderful camera crew here. So that's the team we have today. Okay. Shall I run through the case, Mark? Absolutely. So, from what I understand, it's a 56-year-old gentleman who is, he runs a barbecue business, and he enjoys weight training. And he has had a six-month history of shoulder pain, diagnosed with a rotator cuff tear. He's had six months of rehab, despite that he's got night pain and pain on exertion, and hence he's decided to go down the surgical route. He's otherwise fit and well. I think you've given him a special skin prep. You probably wanted to speak about that, Mark. Yeah. So, just so you all are aware, at least in my area in Tampa Bay, we have a lot of gyms. There's a lot of interest in weight training, so we have a lot of testosterone use. I'm not saying this gentleman uses it, but I've just started having all my patients do a benzoyl peroxide wash that they do, and they begin that three days before surgery. I think it helps with both arthroscopy and with doing arthroplasty, and so I've instituted that into my care. All the patients get IV antibiotics before we start. We do a very thorough wash of the patients before we actually begin. And you can imagine, I'm just pointing at one of these portals that I have. You know, if you're putting an anchor through the skin, then obviously that anchor could, in fact, encounter some bacteria. So we really want to do a nice job prepping and prepping the patient before surgery. So what we're going to do here, so I'll show you guys, I'm in the, and I can show the portals. I'm actually pretty slimmer than Dr. Morris, so I like to start with a posterior portal. My scope is in a posterior lateral portal, and then I use this spider because I get a tremendous amount of ability to distract or move, so I can lift up a little bit, and that gives you this tremendous view of the actual tear. If I go to the 50-yard line, so I'm going to pull the scope out of the posterior lateral portal and stick it into my direct lateral portal, and you can see this cuff tear, right? So it's a, he's got some chronic, a little bit of degenerative changes. I mean, obviously, he's 56. If you go into the joint, you know, and I kind of have, I'm going to have Mike jack the pressure up just a little bit. You can see the articular cartilage, though, is great. So this is a guy who lifts weights, but his cartilage is good. His biceps actually looks wonderful. His biceps looks good. So that's pretty nice. So you can see the edge of the articular margin, and I'm also going to put my anchors just off that. So here we go. We're pulling back out, and I'm going to take a switch stick, because I like to actually look through that posterior lateral portal when I'm working, and I'm going to come back in over there. So what Dr. Franke is going to do is she is actually going to take a awl, and we're going to use, and you guys can speak to it a little bit, this anchor that my tech, and see, I'm pretty impressed. My tech, actually, I put my first G4 anchor in in 1991, so just about 28 years ago. And so what Kim's doing right now is doing, getting this in the position. Mark, before you go further, can you show us how much flexibility, how much excursion you've got with your tendon? With the tendon? Yeah. Grasper, please. So what Alan's talking about is, you know, this is a, really, we should be able to pull this right over. This tendon is mobile. We can pull it over. I mean, it's going to have no problem covering the footprint. So it's very flexible. There's no scarring, really. It wasn't really retracted to start with. I think you would probably consider this like a chrysanthic-type tear, you know, no need for margin convergence or any of those fancy techniques. So this is something that a Navy guy like me can do. I can get this fixed. So I'm going to come down, and that's, Kim is going to pound on this and not hit my hand, I hope. All right. So let's see. So I'm going to put this. This is a straight crescent tear. You're getting, I think, equal tension on both sides. Right. So I'm going to use this like a, you know, goalpost or either side of a soccer goal. We're going to have one anchor in the front and one in the back. So she's going to put this down, and she's hitting it down pretty, a little bit more. And we, so what we have, we're going to use a tap, and I'll tell you why. So I'd like to use, because this guy is, I think, I'm considering 56 young guys. So I'm going to actually tap this. So Kim's coming in with the tap because what she wants to do is get into that hole that we created. Because I'm going to use a biocomposite anchor, and thereby, you're really not going to, this will get absorbed by the body over time. There's no material in there. I think it's a wonderful thing for a younger patient with good bone. But if you don't tap it, you know, they're not as durable as maybe a peak anchor. So I really think it's important to tap the bone. And luckily, Kim's a lot stronger than I am, so she's putting this thing down. So this anchor that we're going to use is Dynacord. It's triple loaded because I'm going to alternate horizontal and simple sutures. The actual, this is designed for residency programs because the knot actually gets tighter over time. So if the knot's not perfect, we're going to have perfect knots, but if the knot, you can take it out. If the knot's not perfect, then it will actually tighten because of the unique design of the core suture. So Kim's going to take that down, and you can see this is, you can hear it, I don't know if you can hear it squeak, but it's squeaking as I put it down. And I'm using Stephen Burkhardt's Dead Man Angle, I have it a little bit angled so that hopefully that resists some of the pull of the cuff. I grew up in the city, so I don't know about Texas Post and such, but I have read his book on arthroscopy, the cowboy version. Okay, so once we have this, we're going to go ahead, and I'm moving the actual spider, and I pull it away because it falls away a little bit from my cannula. And you can see how just by moving the spider, this just opened up tremendously. So what I'm doing is I'm going to grab, so we're going to go simple, horizontal, and then we're going to go behind the horizontal to make a rip stop. So Kim's going to load this into the Expresso and pass that stitch, okay? So can you guys see that okay? I'm trying to give you a little bit of a tennis court view here from the umpire stand. We're looking at this, and she's loading this, and she'll come in, and then I've had not too many cups of coffee, so I'm going to try to grab this when we come in. So Kim, grab that, excellent. So she's going to get a nice robust bite. Oh, this is a wonderful device, and I'm just going to catch it. So I'll just have her fire it, and then when I grab it, I'll tell her I got it, and she's going to pull out with the Expresso, and I'm going to pull this back. So Lupe, back to me. So what we're doing though, this one is just good. The most anterior I'm just going to keep as a simple stitch, okay? And so what I'm going to do next is we'll go for our horizontal mattress. So let's do this color. Thank you. All right, so Kim's going to load up the next one here. So this one I'm going to do as a horizontal mattress, and if Alan, you could tell them how the Dynacord works a little bit better, some of the technology behind it. Maybe that would be kind of interesting to the audience. The Dynacord is a unique suture. It has a sheath of ultra-high molecular weight polyethylene, and the core is a combination of silicone and sodium chloride. And what happens once you put your tension on the suture with tying a knot, it gets nice and tight, but like all mechanical structures, there is creep that will set in. And if the creep sets in enough to where you lose some of your tension, then it allows the spaces around that central silicone salt core to expand. That allows water to come in and dissolve the salt, and then the silicone imbibes these water and expands radially, shortening up to 10% of the length of the Dynacord suture. So this happens over a period of 12 to 24 hours, and then is constant after that. So what you'll see is that if you happen to have a loop or a little loosening in the knot you've tied, which some of us always will have that from time to time, then this sort of self-corrects that and adjusts it back to the normal tension amount. The anchor that they're using is made of biacryl repeat, which is a beta tricalcium phosphate, a combination of copolymer of polyglycolic acid and polylevo lactic acid, and these anchors, the material biacryl repeat, dissolves within about three years. We did some studies using CT scans and found that 80% of these implants, they're all gone in three years, and 80% of them show bone ingrowth into the area where the anchor or the interference screw was located before. So this is a very robust device that goes away with time, and you don't have to worry about it with revision cases. So Mark, I noticed when you're doing this, one of the things you've got to be careful of when you're doing this rip-stop technique is that you don't pick up the other sutures when you go in with the Expresso, and I noticed you're looking underneath when you put the Expresso in to make sure you're not picking up the other sutures. Is that right? Yeah, so what the problem is, as you see, I split them. I pulled one out the back, one out the front, and then I had Kim bisect that angle. But if that needle is sharp enough, you could cut your suture, so we don't want to do that. So she did a great job. I had to do a little muscle recovery because one suture went in the muscle a little bit, but was able to retrieve that, so I'm going to pull this back out the front. So that's the first anchor, and then we're going to go ahead and we'll put the next anchor in. But yeah, you're absolutely right about that. So she's dropping the arm, internally rotating just a little bit, and she's going to put the next anchor in. His biceps is good, but if it wasn't good, what would you do? I would tenodese him, and I would do it a high tenodesis, not subpec. So I would actually, I would come down, hang on for, Kim's going to come in, but I'm going to show you just one, just relax. So you can come and bring the arm up like this. The biceps would be right over in this area, but I think if I get, like, then I might put an anchor just off the bicipital groove here and pass the sutures, and then I'd use one of these to put a simple suture through the biceps. So I got it fixed a little bit down the groove, and then right up at the joint, and then I'll come back in the joint and cut it. That way I get the length perfect. Yeah. Okay. So I'm going to let her drop the arm back down and pull down on that a little bit, and then give me the punch real quick. So one of the things I want to reiterate is that this is not being put under tension. He's basically putting the anchors at a point that the tendon can gently reach without a lot of traction. Too much traction increases over-tensioning and impairs healing. You mentioned at the beginning of the clinical something about testosterone. There was a report at the recent academy meeting about the effect of testosterone on the healing of rotator cuff repairs in gentlemen under 70, and they found that if you had low testosterone, there was a significantly increased failure rate compared to those in normal testosterone. Makes me wonder if maybe testosterone testing shouldn't be part of the preoperative planning. Peter, do you do anything post-op particular to help encourage healing in the post-op management of the rotator cuff repairs? So my view is I actually go for a relatively quick rehabilitation. I think moving these early on is a positive factor to encourage healing. So it's got to be in a protected range, closed chain, but I actually think that actually promotes healing. So that's my post-op regime. One of the things I do is based upon a study that was done in HSS several years ago in which they gave doxycycline to rats, and they found that that helped improve healing. So I give my patients 100 milligrams of doxycycline BID for 14 days to reduce the risk of P. acnes and also to suppress the metalloproteinases that tend to argue against— That's really hard, isn't it? The bone is tremendous right now. Sorry, this bone is like super hard. I mean, we got a little crack there, but we could barely screw this in. So let me—I'm taking this back out now, and we'll put this anchor in. But just having a little fracture in that lateral cortex, that's going to help the healing, but gosh, this is really tough bone. All right, so come on in with that. P. acnes is a real—going to be a real problem in the U.K. now, so I presume it's the same in the United States, but basically every time something presents that doesn't fit the normal pattern, usually P. acnes is in there. There's a lot of things that happen that we don't really appreciate until five or 10 years later. Okay. So I went back to the 50 yard line. I'm going to go back to my lateral portal right now, kind of that posterile view that you guys saw earlier. I'll tell you guys too, I mean, I've had, I hate to say that I've had three infections in my rotator cuffs. They've all been men in their sixties on testosterone. And it could be completely, you know, by chance, but it makes me nervous. And so I'm really kind of pretty compulsive about the, you know, the, the wash, the benzoyl peroxide and everything else we do. Okay. So I'm going to move the arm a little bit. Can you hold the camera? I'm gonna have Kim hold the arm, but I just want to put a little traction on the arm now to get the back and internally rotate just a wee bit. All right. Got it. All right. Let's get Kim back. So then she's going to go ahead and grab that. Okay. So she's going to do the next one. So you know, Alan, I think the doxycycline is a great idea. A lot of people, you know, the healing you can get with that and everything else, and it's pretty good against the QT bacterium or the P. acnes. So now we're going to, so we kind of got this up front. So we're going to go simple, horizontal, and then a rip stop behind it. So what I'll do is because I have this accessory posterior portal, I'll come in with a straight penetrator from the back. Go ahead, Kim. So this is not a rip stop, simple. So Kim's going to grab it. Right there's perfect. I got a grasper. Push down on this a little bit more when you do it. So just we didn't, you know, go ahead. One of the things too, as we do this, you know, I kind of keep, still keep my folks locked up for six weeks. I don't know if you guys do anything different than that. So I moved them. So I moved them, I put them in a sling, I asked them to wear a sling for four weeks, but that's to remind them not to do very much. But I start them moving with a physiotherapist on day one, closed chain, in a safe range. So that's partly a function of how secure the repair is, what the tender quality is like. But I like to move them in a protected way early on. And I'm just the opposite. I don't like to move them at all. I went through the phase of accelerated rehabilitation that kind of spilled from the ACL, from Don Shelborn's work in the ACL to the shoulder. And I started getting MRIs on every patient post-op at about four months. And I was disturbed by the incidence of re-tears. And so I cranked it back. I guess I may have overreacted. Now I keep them in the pillow sling for three weeks, then take the pillow off and keep them immobilized for another three weeks. And then I'm happy when they come back at six weeks and have about 50 degrees of abduction and 30 degrees of forward flexion. I consider that a win. I'm concerned about the guy who got 110 degrees of forward flexion because I don't think he's been compliant. Let me get a switching stick in there. You're good. I have very few patients at four and five months who have significant motion loss, though. And we don't really release people to full activity until six. Okay, hold this here. And then give me the straight penetrator and we'll go outside. So hey, so here I did the same thing. This is my second ripstop stitch. So I got one. I'm going to have Kim hold it because I don't want it to drag on the drape too much. So you can see the front one, the back one. And what I'm going to do is from the outside, if you can show this, we're going to go to the outside. Just so you guys can see this. This is my favorite little move because I think you can get a little bit of a bigger bite. So I'm going to come in and I aim at the orange cannula in the front and I don't even look at the camera screen too much, but I'm in the joint and I want to go between this goal post and this goal post right here. And so I can cut through and I can basically penetrate through that tissue with this. You can see this little device. It's like a bird beak. And that way I come out and I'm going to get one of these white stitches right there. And then I'll just pull this back out the back. So that way I didn't cut my suture or anything. So now when we tie them, we'll tie our horizontal mattress first, loopy. And then she can tie the simple behind it so it acts like a ripstop. So here I'm going to grab these two and do one at a time. What kind of knot are you going to use? So I went to Mississippi a long time ago and watched this guy, Buddy Savoie, who is amazing, do this modified rotor knot. So do you have both of them or just one? So this is going to be kind of a model. Keep the one out the lateral side. And where's my other one here? Pull it. Pull. All right. There it is. All right. There it is. Yeah, I got it. OK. So this is a modified rotor knot. It's basically like a Duncan loop. Let me get that other. Yeah, you're good. You're good. No, you're good. You're good. You're good. But then it locks. And what I've done is because we, I don't know if you can see Kim from the outside, but what she's doing is she's putting the knot pusher, and I just do this so when we have the new fellows that they don't drop the knot pusher on the floor. We got it hemostatic. She's kind of coming around three times, and then she'll go through the center. And then when she's done, she'll come back through the other loop. Now this actually isn't locked. When she comes back through this loop, it's just a Duncan loop basically. It's just going to slide. But she'll put a half hitch behind it, and that will lock it. And then she has a knot pusher already attached. So when she gets this and she'll pull it to the dam, the less work you do outside the joint the better. So you kind of get to here. And then she's going to push that down. So she's pulling on the post, and this is going to just slam down into the tissue. And this is that wonderful suture that should even get tighter later. So she'll hit it, and it's a little bit, the handling is a little bit different than the orthocord. I know Doug and Alan know that. So she's going to tighten that, and then she'll pass post. And then she's going to really give this one for Montana and really bring this down tight. So the thing about her, she knows how to shoot and rope, so I have no problem having her tie my knots. So this comes down really nicely. And she's going to put the next one down, and she's just going to slide these down on the post, sliding it down the cannula. Just like that. Just drops right on, lays down. And then I got Mike's going to tilt the pressure up a little bit just so you guys get a better visualization. But I think it's really important to tie knots when you're learning. You want to make sure these knots, you have knot security. And the nice thing about this suture is it will give you a little bit of latitude. I mean, we don't want to have slack knots, but the suture itself will tighten over the next 24 hours. And she'll do one more, and she'll really kind of pull that down. And then we're going to cut that. So thank you, Kim. Get rid of the cutter. All right. So a little bit on this, too. I don't think, you know, we talked maybe a little earlier before you all came back in the audience. This isn't a case that I would use a double, I don't think you need to do a double row here. But once I get to here, I can take the loopy back, and now I'm going to tie the suture that was behind it. So, you know, we know this is my post, so I'll give Kim the post, and you can hold that in your hand. And then I'll take my non-post. It should be my non-post right here. Okay, so then she'll tie the next one. Okay, but I think this is nice because it kind of gives you the benefit of having a rip stop if you alternate the horizontal and the simples. Give you a little bit more of a perspective here. And I know all you guys can tie knots, but we're just kind of going through that. How about you guys? What kind of knots do you like to tie? Alan, what do you do? My preferred knot for a rotator cuff is the SMC knot. And my preferred knot for the glenoid is the Tennessee slider. The Tennessee slider has a little bit lower profile, and the stress in the glenoid is lower than it is in the rotator cuff. And I did a study comparing different kinds of knots, and the top two in that series were the SMC and the Tennessee slider. We saw what Pettowitz reported, which was that with these ultra-high molecular weight polyethylene sutures, they have a tendency to slip before they fail at sub-maximal breaking strengths. So, you know, the takeaway message is that the polyethylene is slippery, and you got to make sure you tie locking knots. So I prefer not to use a fisherman's knot or one of those Duncan loop or hangman's knots because they don't have an internal locking mechanism. Peter? So I'm the other boy. I used to use the Duncan loop, but then I've gone to just three or four overhand knots as my sliding knot, and then I throw three half hitches on different posts to lock it off. And I like that because it works as my sliding knot, but if it becomes a non-sliding knot, it's basically the same knot, three half hitches built up the same way, and then swap it around. And so it just keeps it simple. Everyone knows what I'm going to do. So the gentleman from Liverpool, you know, I think that is critical. When you get your initial knot down, that's great, but having those three alternating hitches I think is critical, too, to make sure that this thing doesn't back off. So once she gets this next one down and she's kind of bringing it through the canina, she's going to really crunch this down, and she's going to pull that tight, and she's pulling it tight, and then we'll cut that. But I think that's really important to alternate those, and you can, I mean, I can pull on that knot. I mean, that's nice and secure. I mean, you know, and pull the whole tendon, and it's not going anywhere. So I mean, and, you know, we got a lot of really smart people there, and you know that having more points of fixation is probably better, and that's why I really like this triple-loaded anchor. Do you have another? So we'll get the next one going here. So and do you guys like to also, because, you know, we made this bleed a little bit, kind of we created a little bit of that crimson duvet, and then again, I did an acromioplasty and a distal clavicle, so, you know, you're going to get some bleeding in here. Do you guys also do the same thing? Pull that for me. So I will do an acromioplasty if it needs it. So my object is to end up with a flat acromion, so if it starts off as a flat acromion, I won't do the acromioplasty, but if there's any curvature in it, then I will do an acromioplasty, but it's a function for me as to whether there is evidence of bony impingement. If there is, I want to remove it. If there isn't, I'm not bothered. How about when you were at best this year, are there a lot of people who don't do acromioplasty in the United Kingdom, or do they still do it, or what's the kind of current trend? I would say that probably 90% will be doing an acromioplasty of some form with their repair. So are you alluding to the subacromial decompression paper and avoiding subacromial decompression surgery? Yes. So I've been the president of best for two years, and I can tell you, I'd much rather talk about something else because it's all I've talked about for two years and I've had enough. Okay, we'll talk about something else. So who's going to win the Seven League Rugby Series this year, or Seven Nations? Is that going to be England again, or Ireland, or what's going to happen? So certainly that has been and gone because Wales won it, and England snatched defeat from victory, which is the tendency to do it. The pastos didn't really pull hard on both of them. All right, so Kim is going to crush this one down too. Oh yeah, nice. All right, so we're kind of going to work our way across. She's going to put some half hitches behind this. But one of the things I've had, I've been using this now since it's come out, and I really, really like the handling properties of this, and I like the fact that I've got my third stitch in here, and it's great. So I'm going to switch with her in a second, and I'm going to tie. I'm going to see how my hands are doing tying a little bit to get in the game a little bit here. So for me, I like to let that slip. See, that one wasn't down all the way, but we are going to make sure that she's going to crush that, and she's crushing it. But I keep people in a sling for six weeks. I let them come out to work on the computer, though. It seems like, at least in my practice, my patients really enjoy being on the computer, and if they can do that, they're kind of happy. I make them wear it at night. I begin the physiotherapy at six weeks. I think it's important to have them see someone to work on range of motion. So that's kind of been my practice. I really don't use an abduction pillow ever. I really haven't really bought into that too much. So we're going to switch. So Kim's going to give you a little view here, and I'm going to tie the next one. Let me have a loopy, please. Mark, this is a really good view, but time is marching on. We've only got a couple of minutes. So could you just, at some point, run through your plans for how we're going to finish this off once it was all tied? Oh, yeah, sure, sure. So the plan here is that I'm going to tie this other goal post and bring the simple behind it, the simple. And that'll be this one tying. I'm going to have Kim show you. I can show you from the side. This is a cannula coming in, but we just want to close down the rest of the front. I know you guys are limited on time, so I'll start tying this one one time. I love the fact that I actually get paid to do this. That's what's amazing about our job. I like tying knots. Like I said, probably my days fishing when I was a kid were the best thing I ever did because I spent all kinds of times tying knots and tying stuff. So I enjoy it. I think all you guys do too. You wouldn't be here. It's a lot of fun. I think that the new anchors and sutures and things that industry has provided us is absolutely fantastic. So it's a lot of fun for me. I just think the critical thing is when you're tying these, and you can see I'm going to pass post this pretty hard when I do it and pull my trailing stitch. But I think you want to have this nice, even distribution of pressure when you tie things down. You pull really hard, you get that knot down. You want knot security. And having a stitch that makes up for that a little bit is just fantastic. So I've been really excited with this new product. I've been excited with the team I work with. And I think that's part of the game. Like I said, I've got a great group of people helping me here today. I've had Stacy who's been working with me for probably five years. And I couldn't do it without her. Just wonderful. So I thank everyone for watching. Hopefully you enjoyed it. And have a great time at the meeting. Yep. So thank you. Thank you. Would you pass over our thanks to the theatre team? It's a great demonstration, and we've enjoyed watching it. Thank you, Mark. Thank you. APPLAUSE

rotator cuff repair

surgical procedure

sutures

anchors

post-operative management

testosterone

antibiotics