Anchors, Sutures, Knots? My Technique for Arthroscopic...

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


Disclosures

Depuy Mitek Sports Medicine – Speaker / Education

Smith & Nephew - Consultant


Technique

Positioning◦ Lateral decubitus vs beach chair

Repair configuration

Number/type of suture anchors

My technique for anterior stabilization


The great debate . . .

Does positioning in the OR play a role?

“Arthroscopic” vs “Shoulder” surgeons


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


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


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


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


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


“Lastly, the number of suture-anchors was critical: patients with three anchors or fewer were at higher risk for recurrent instability (p = 0.03). “


Portal Placement

Posterior

Anterior - Superior

Anterior – Inferior

Posterior – Inferior

(7 O’clock)


Anchor Placement


Evaluate the lesion

Verify little if any bone loss

Complete release from the glenoid

Goal to have a balanced repair


Elevate


Complete release


Repair

Start with a 7 o’clock anchor

Then march up from 5:30 employing a proper capsulorraphy effect from inferior to superior


7 o’clock anchor

Right shoulder posterior viewing portal

Left shoulder anterior superior viewing portal

7

4

56


Capsulorraphy

Typically about 1cm

Beware in patients with hyperlaxity and the very young


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


Thank you

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