So, I think we're ready to go. Adam Morris from Florida Orthopedic Institute is going to step in and show us how he does a rotator cuff repair right here in Coward Wood Hospital. Adam, are you there? Yes, I am. Thanks. Great. Why don't you tell us a little about the patient and your setup? Okay, this is a 71-year-old female. She had an acute on chronic injury about two weeks ago. She had a fall. She had full range of motion before that, and then during the fall, she lost everything beyond about 30 degrees of abduction and forward flexion, had an MRI scan that showed a medium-sized full-thickness retracted tear, and we talked to her about options, and because she had so much loss of motion, we opted to go ahead and treat her surgically. All right. Terrific. So, why don't you talk to us about your portal setup and show us what you got? Okay. So, we're going in live from the top. We have a standard posterior portal back here. We use the Accessory Navasia posterior lateral portal to get better visualization of the rotator cuff tear. I don't know if you can see inside or just outside, but this gives us a better view of the tear and the rotator cuff, and then we use a—you can either use a single portal, straight lateral, and then put your anchors in from there and then go in with your suture passing device in the same portal, or you can use a double, a higher and a low portal, one right off the acromion, so you get better angle coming into the bone, and then the lower one allows you to pass your sutures and grasp them without impinging. And then we have an anterior portal that we use, a standard anterior portal, for your subacromial decompression, distal clavicle excision, and for suture shuttle out the front of the shoulder. So, you can use anywhere from three to five portals, depending on what you feel comfortable with. Is there any need for an arm distractor or an assistant pulling down on the arm during the case when you have beach chair? With the beach chair, I think it's more of a convenience to have either an assistant with the arm. We use the spider. That's what we're using here. The nice thing about that is you don't have to have the assistant pulling down on the arm getting tired. The spider will do all the work for you, and if the assistant runs out of gas, it gives you the benefit of that never gets tired, so we don't have to worry about somebody complaining that their arm's hurting because they're standing here working and holding their arm for you for the whole time. Okay, terrific. So, why don't you get started and show us what you're doing? Okay. Can we go to the inside? Okay. So, this is, we've already done our cleanup inside the joint, and then we came subacromial. This is the edge of the rotator cuff. You got a probe or something? This is the edge of our rotator cuff. Here, you can see the biceps up front, which looked fine. It was all intact. We were able to move that in. It's still in the groove and not displaced. The subscap looked fine, and the infraspinatus looked fine, so we were basically just focusing here on the supraspinatus. We went ahead and cleaned up all the tissue off of there, so that's probably the most important thing you can do is make sure you have a clear field so when you're passing your sutures, you can go ahead and make sure that they're easily visible and that you can get that tendon back down exactly where you want it. Now, we'll use a two-row repair, so we'll come in with our tap, and the tap will come in, and you'll tap that down into place. We went ahead and already tapped this one once, so just to show you how that works. Are you thinking ... You said you were going to do a two-row repair. Does the size come into your thought process when you're deciding between a single and a double-row repair? Yes. If I'm using a single-row repair, I'm typically going to use only a ... For a smaller, smaller tear, but most of the larger tears, I want to recreate the entire footprint, so that's just my habit is that I will always do a double-row repair. Now, if you look at this ankle, this is the Smith and Nephew anchor. It's cannulated down the center to allow the blood to come back in and actually incorporate into the repair from the inside of the bone, and it also has these fenestrations. If you look at the side of the anchor, once you remove this, it's fenestrated so that the blood can come in both from the side and from the bottom of the anchor, so when you get it in there, it actually gives you a lot of blood flow, and it resorbs a little bit faster and it incorporates into the bone a little bit quicker. In terms of placement of that first anchor, are you looking at the articular surface? Are you coming as close to it as possible? Yes. We're usually just a couple of millimeters off the articular surface right there, and then we want to come in as vertical as possible so that we're not skiving underneath the articular cartilage. Typically, I will only use ... These are double-loaded anchors, but I'll typically only use a single ... You want to pull one of those, and I'll take the loop grasper, and then basically you can come in for our passing portal and just pull those out of our lateral portal, and then first pass. You want to come hold the scope? Are you planning on doing an antergrade pass? Yeah, we'll do a pass straight through the undersurface of the cuff in a horizontal mattress-type fashion. Just make sure that we don't over-tension the cuff, so we want to make sure we're getting a decent bite and healthier tissue and not over-tensioning the cuff, so we'll just pass that. If you were concerned about tissue quality at this point, would you necessarily change the suture type or the suture configuration? I think that habitually I tend to stay away from ... Typically, the suture configuration would be the same no matter what. I just have found that this configuration seems to be pretty stable, because I've got a backup plan where if the side-to-side is too close together and it ends up tearing through the tendon, then I still have the lateral row, which is going to allow me to have a solid repair. Then if I ... I'll take the tap again. One of the things that was brought up in one of the prior lectures is trying to limit tension on the tissue. With the device you're using as you pass it through and retrieving another portal, this often helps prevent ripping the suture through the rotator cuff. I'm sorry, repeat that for me. As opposed to some anti-grade suture passing devices that grab the suture and you have to pull it out through the same portal, the way you're doing it allows the pass and grasping it from a separate portal without putting tension on that suture and having it rip through the tissue if you bring it out through the lateral portal, again, through the same device. The device that we're using is the Smith and Nephew FirstPass. The reason ... They have a self-capture like you're talking about so you can pull it back through and they have a non-self-capture. I typically only use the non-self-capture for that very reason. If you were concerned about bone quality here, how do you change the sequence events that you're doing? The sequence won't really change. I started off, rather than use their standard 4-5 anchor, we switched to the 5-5 because we tested the bone quality and it was questionable, which is typical for a 71-year-old. Normally I would start off with a 4-5 anchor if I wasn't concerned with the bone quality. With these particular anchors, do you have to tap all the time or is there a punch option to limit the amount of bone destruction? This is a punch tap. You tap it in until the threads catch and then you go from there. I would not recommend doing this with this lactoabsorb anchor without a full tap. The rationale behind that is it's a trade-off between the strength of the anchor and the reabsorbability and the fenestration. I like the fenestration because I think I'm getting much better blood flow. You can see that we're pulling really hard on this and you can see her shoulder shaking, so we've got real good quality bite with this anchor, with the 4-5. If you've got somebody who's much younger and much harder bone and you try to put the anchor in without tapping it, you can damage the anchor that way. The trade-off is that if I use the tap and pass the anchor how I like to, then I feel much more comfortable. You spoke about leaving the biceps in the 72-year-old female because it looked good. What if she had a degenerative type slap tear? Is there any change? You were questionable about whether it was causing her pain. How would you approach that? As a sports guy, I would say that in a 71-year-old female, I wouldn't try to repair the slap. I would go ahead and just release it, do a tenotomy. If she was younger and I was comfortable with her function or activity level being high enough to warrant it, then you would do a tenodesis on her. What's your approach for tenodesis? Intra-articular, sub-pec, super-pec? We've done all of them. What's the rationale for not using the second suture in that anchor and getting some more fixation potentially? I think you end up with too much medial fixation. I'm a little bit concerned that if you do that, you're going to end up with suture poisoning and get too many knots. I just think it's overkill and unnecessary. So typically, we always put our anchors in anterior to posterior, and then we always tie posterior to anterior and make suture management a cinch. And you're tying from that far lateral portal? Correct. Do you ever change which portal you tie from after you put these anchors in, and the sutures are passed? No, usually I either do it from the lateral or the far lateral, unless there is some reason why it can't be done that way. And what knot are you throwing now? This is just, it's a fisherman's knot, so I typically throw an over-sew of half inches over no matter what knot, whether I use the SMC knot or the fisherman's knot, so once you're doing that. And the plan is after you tie these, these are going to go through a laterally-based anchor? Correct. Are they going to be passed in a criss-cross type fashion? Yes. Have you ever wanted to use tape, or if you had a tape option that you can place in those anchors that you had, would you use it? I have used tape, and there are a couple of companies that make a good tying tape. Some of the tapes I've found tend to bunch up and not tie as well, so I've had some issues with using tape causing issues, so I've switched back to the suture, but there are a couple of companies that are making a little bit better tape now that gives you that option. Also how do you decide on how many medial row anchors you use? Basically just by the size of the tear, so in this case, because there was about a three to four centimeter tear, we'll go ahead and put in one at one centimeter intervals, and then just as many as we need to on top of that. And if this was more of a retracted tear, can you just take us while you're tying this down through your release technique, and how do you approach a retracted type tear? So usually I'll pass a couple of sutures through the rotator cuff and use them as tension stitches, and then I'll start on top and free it up, make sure the interval is free, and then make sure you're free all proximal with an elevator, and then if I feel like I still don't have the movement that I need, I'll go to the articular side and free it up just superior to the labrum, and make sure that I've cleaned that off and I've got that all the way back the way I want it. Do you make an attempt to look for the coracohumeral ligament and release it at the coracoid level, or you- Absolutely. And then if you look, so our tendon's back down to the bone, we're pretty comfortable, we're clean all the way across, so now it's just a matter of taking those, crossing them over and then giving us a lateral row, which I'll show you next. You can see laterally where she did have a small cyst in the front of the bone, but we went ahead and took off, she also had a spur across the lateral acromion that we take down, and then create a little bit of a Steve Snyder crimson devee. Have you moved the arm positioner in any way while you've been doing this? Yes, when we, yeah, my assistant, Dr. Mark Mile, in here is helping me with the elbow, but when you're headed to the posterior, you'll internally rotate the arm like this, and then when you're coming back toward the anterior anchors, you can rotate the arm externally and then lock it in place with the spider while you're working to get that taken care of. Now, is your plan to put the posterior anchor in first, and is there a reason why you choose the posterior or the anterior first when you're putting your second row in? I don't think that matters as much, but mostly it's just for visibility, it's easier to put the posterior anchor in first. And are you a subacromial decompression guy or acromioplasty guy or not? Yes, I feel that. You can see we did a small subacromial smoothing. She didn't have a huge hook, so we didn't have to worry about that as much as we would on somebody who had a type two or a type three, but I think if you make sure that you've got enough space to where the anchors, the lateral anchor, the footprint, yeah. So for the lateral row, we're using these peak anchors. It's the Smith & Nephew, another Smith & Nephew product. You pass your sutures, you separate out one of each anchor and pass them through the little loop of suture. And what size is that? This is a 4-5 again, or sorry, a 4-5. We use 5-5 on the other set of anchors, and these are just a 4-5. Is there a 5-5 option in this if you wanted to use it? Exactly. If I'm concerned that the quality is not as good, then I would use that 5-5. So I'll put the hemostat, sorry, thanks. And then hold this out of the way until we tap. How do you determine how far you go down laterally when you do your double row repair? So I like to make sure I'm off of the greater troch, and I like to make sure that I'm not angling directly into my others, so we don't create, if you put your ankles kind of close together and you angle your anchor in the same direction that you're converging on your medial row anchors, then the concern is that you're going to possibly create a bone wedge that can actually break off. So I'll usually cheat down to where I'm comfortable, I'm coming in low enough, oops, let's do this. To where my ankle is far enough off that I can, I'm not worried about having a little suture laying down, but I am worried that if I come in too low, I'm sorry, if I come in too high, I can create that wedge and converge right there. And have you, for some of your larger tiers where you're putting multiple laterally based push anchors in, do you alter that lateral portal, do you make a separate portal sometimes to avoid penetrating the articular surface sometimes with these lateral anchors depending on the angle, or you haven't had the need to do that? No, it's certainly an option. A lot of times we will do that if it's necessary to get a good angle on it. If we feel like we don't need to, then we would avoid that if possible. But certainly if there's an angle that I'm not comfortable with, then the easiest thing to do is to protect it by going ahead and putting the second incision in, because an added arthroscopic incision isn't going to change too much, but it's going to allow you to... So the benefit of this anchor is we don't have to actually tension it before it goes in, we can actually keep these loose and tension them now, and you can see how we're tensioning these anchors right down how we want them. And then once we get it there, there's a knob, I don't know if you can see this on the outside, but the actual anchor will then screw in and it'll actually clamp the suture once it goes in there and you're just waiting for the click and the pop. And then once it does that, it just unscrews. When you're putting your lateral row anchor, are you concerned about the sutures getting caught under any of the other sutures that are there, in terms of preventing you from using that anterior anchor and really socking down those second two sutures laterally? No, I'm not concerned because it's pretty simple to go in and just pull that other suture out from underneath it. So you'll see me do that in just a minute, is that while I get the cord cutter. We'll just cut these sutures now that we don't need them anymore. Again, just like we found, this anchor's kind of not holding very well. The medial 5-5's held really well, this lateral row's not, so we're going to go ahead and switch out to a larger anchor. See if you can give me the grasper. Are you able to, if you were able to push this in a little deeper, potentially stack it as an option, if it was less loose? Yeah, I think that's certainly a reasonable option. If you feel like it's not going to do it, we'll actually just take a second anchor and we'll just stack it right next to it to give it a little bit more support. Give me the 4-5 tap. Are you trying to grab the backup suture? No, let's make sure we get a fixation, because if we need to use it again. So we'll push that anchor in and then go ahead and just tuck another one right next to it. That's still pretty soft. Now I'll take that second anchor. The 4-5, 4-5. So yeah, I think we have the option of taking that anchor out and putting a new one in, or we can just stack a second anchor next to it like this. this the blue you over here on yeah not here in this one sorry so this is that other blue anchor that we were tied underneath just to make sure that it doesn't get pinched or in the way we'll just move it like that yeah yeah we'll just cut all these cutter another cord cutter have you ever thought about in these cases do you augment it ever with a a patch of some type to stimulate biology like dr getterman gave us a little talk before about that i don't think that's a a bad option i'm just not completely convinced that um that's necessary i have used it in the past when i like on a revision case or if i was concerned Now, in terms of your thought process about anchor size, are you using the larger 5'5 anchor up front here? So yeah, because of what we got on the other side, we're going to try a single 5'5 rather than two 4'5s to get it to hold. And outside of that... And the bones will be a little bit sturdier over here by the bicipital groove, so we shouldn't have so much trouble over here. Not to jinx anything, but let's say the 5'5 didn't hold well. And then you can still stack it with another 4'5 next to it and be fine. Right. I need a... I never quite understood why they didn't make a 6'5 in this type of anchor, but I'm sure some of the companies have a 6'5 version. I lost my suture, so I'm going to... Oops. Do we have a hemostat on there or something? So yeah we'll go ahead and it's really short hemostat. You took the cannula out because the sutures are short? Yeah one of one of the sutures came up short. Okay. So I'm gonna we went and took that cannula out so we can make sure we got a hold of this the white suture which is a little bit short. There it is right now, hemostat. And then our punch. Now is it possible that there's a smaller punch on the set, especially for, with the poor bone quality, or you just use the, can you just use the starter on this punch and just get a little hold? The same four or five punch that we use, even though we're using the five five anchor. Okay. Because of the softer bone. And then we won't sink it all the way either, which will help give us a little bit more bite down in there. No pressure on time, you have a minute left. Do we really? Oh yeah, you're not kidding, okay. We're almost home. Yeah, the bone looks better there. Yeah, we got a lot better quality bone across the front there. Any bailouts that you can give us if that suture was indeed too short? Are there any shuttling options, or you've kind of bought it because you've tied that medial row already? In part of it, we bought it because we tied the medial row, but at the same time, we have it tied medially, so we can just pull one suture laterally and cut that one off at the medial row, and still be fine. Okay. So we haven't completely lost anything by doing that, it's just gonna be a little bit better fixation and a double attachment to that row if we can do it this way. Sorry, I saw that you used the snap to open up that portal to prevent a suture bridge from happening. Correct. So we went ahead and opted to just leave the other one since it didn't seem like it was going to go. So one of the limbs are in there. Got it. Yeah, so one of the limbs is in there to kind of hold it down and we'll just go ahead and cut the other limb off. Yeah. If you have a dog ear remaining, is there an option in this anchor to pass an additional suture or what would you do? Would you put an additional anchor anteriorly and what type of anchor? I think you could just use, this anchor will hold approximately eight sutures. It's a fairly large anchor as far as the opening. So it gives us the benefit of we can add any, if we feel like, hey, there's a dog ear in there, grasp her. We can go ahead and just go right through there and add in the simple suture to there. If you can give us a final view, Adam, we're going to wrap this up as our time is over. And then that's the rotator cuff after it's repaired. Okay. Thank you. Thank you for your presentation and a great bailout on that poster anchor. I think those are always challenging. Thank you. You bet.

rotator cuff repair surgery

71-year-old female

acute on chronic injury

full-thickness retracted tear

portal setup

Spider arm positioner

two-row repair technique