In this short, fundamental case, Dr. Patrick Vavken performs a cadaveric rotator cuff repair by placing the anchor, retrieving and passing the suture arms, and tying the suture.
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- Using Posterior Portal for Visualization, locate rotator cuff tear and debride edges
- Evaluate size of rotator cuff tear. Number of anchors used will depend on size.
- Using Superior Lateral Portal, position anchor and drill into bone.
- Mallet anchor into bone and release anchor.
- Using retriever, retrieve 1st suture arm through Superior Lateral portal
- Pass suture arm and take suture "bite" into cuff to be attached
- Retrieve 2nd suture
- Pass second suture arm
- Tie arms using an Arthroscopic Knot
- Cut suture ends above knot
- Repeat with more anchors as needed
Alright guys, we’re back. We’re looking at cuff tears. We want to do an anchor and a couple away, sort of pass the stitch. You can see it’s a cadaver shoulder. We took out the biceps tendon. There’s some synovitis. We started debriding the cuff tear. This obviously is a large - a massive tear since it's at least 3 centimeters that goes into infraspinatus. This should usually be a 1, 2, 3 anchor - maybe 2 anchor triple loaded problem. We'll just do one for teaching purposes. You can see that we medialized the footprint a little bit. It’s usually done only for - in case of retraction, but, you know again, out of teaching, that's what I want to do here.
Bring in the anchor. We're going a little bit abduction to get better access to the footprint. You can do this from intra-articular, extra-articular. They - there is decompression up there, and looked that our - our bursa. Anchor’s coming in, coming up steep. Little more abduction. So you go a little more medial. We’ll compromise position for visibility.
So this is our tear. It's very small. We’re going to put in an anchor right in the center of the footprint. You can see the cartilage right there. Then comes the drill. Pull bottoms out. In goes the anchor. There you go. Push the white button. Pull all the yellow handle up. Untwirl just the top part, and just pull out. There you go. Keep pulling - and then pull the sutures for a nice click. There you go. Alright. We’ll be using an cannula over the sutures. Got a retriever. Thank you. Retrieve suture number one. Put back in the cannula. And I get our passing device.
Couple things can go wrong using this passing device. Put in the suture. We’ll give the camera to Cal - Caleb’s assistant. Close it. Now if you just stick it in like this, you'll l - lose the stitch. If you don't close it, you'll lose to stitch. So we want to close it. We want to - we want to hold the stitch at the end of the cannula and then go in all the way. Now we’ll be struggling with the cannula. Now that we’re in, we can pull it back all the way. Now we don't need it anymore. Once in, we open again. Get a good bite of what we want to bite. Close. Put - this is the opening and closing mechanism, so this is how you open. You find where you want to be. You close down with your index finger. It’s a little short. I'm going to grab a little more - a little more - and then by squeezing the handle as such, the stitch will come out here. And we’ll catch in the suture passer - the 2nd generation. This one will pull out everything - suture and cannula and all that stuff at once.
Now back in goes to cannula. We’ll find our suture grasper. Reach back in for our second stitch. Let go of the stitch for a second, please. Come here. Pull it out. Cannula goes back in. Load the stitch again. Pass it through the cannula. Go back in, the cannula will come back out just as before, giving us the space to open the tool. Tool will go in. We’ll try to place it parallel to our second stitch. Fire. Pull back everything at once.
Cannula goes back in. Stop for our stitch. Suture pass-through-er follows. Finding our second stitch - making sure both of them go through the cannula and are not tangled. And at this point, we - we tie. Unless of course, like we did just now, we unthreaded our other stitch, which is no big deal. So we go back in, grab our stitch, come back out. We’re untangling it. Go back in, grab our stitch - you want to try? Index finger opens - no, index finger opens. Grab - grab the far end of the stitch because something's it will cut through the the stitch - far end, even further. Close. Hold cannula, go through cannula, all the way in. One finger will hold the stitch - wait, like right here, your thumb - there you go. Keeping some tension, go all the way in. Pull the cannula all the way back. Index finger opens the tool. The bottom will slide into the hole. We got some purchase. Make sure we’re parallel to our other ones. It's going to be nice mattress. Come down a little bit with index finger, 5 millimeters away. There you go. Index finger closes all the way, and then squeeze your hand to fire. Release your hand, index finger opens the tool, and then you pull back everything in one ultra bang. Alright. Wait - wait - close. Open. Pull towards you. Cannula goes back in. Suture grasper follows - gets the other suture.
And now, pull tight. Any knot will do. Personally, the Duncan loop is old school, but it's simple and has the beauty of you can pull it back if you don't like where it sits. See you bring your hand back. Post, strand, or go over around for once, twice, 3 times, 4 times - original description - I like 3. Get the end. We’ll go through here. Catch the end again. Goes up. And grab this, and then with the same amount of pull and push, we’ll just bring down the knot. And Jake was going to find it in there somewhere. Just look for the cannula - little lower, little lower. There you go. That’s our knot, and if we don't like it for some reason, we can always - you could even pull it back up.
Alright, so pushing down onto the knot, onto the anchor, pulling, pulling one strand, keeping it stable, and I'm going to lock it on the other side. Bang. Come back out. Little snappy can help keeping traction. Over and through.
Handing this to myself, we’re going to walk the other knot down. And same as before, pull on post - tension, tension, tension, tension, tension - pull on strand to flip the knot. And then just gently tilt over the button, over the anchor. That way you can lock it without pulling out the anchor. Don't pull up here. Don't point - pass point back here - just come down onto the anchor and then just tilt down into the anchor. So you’re now pulling out the anchor. Coming out again, another knot, locking it down, pushing on post, pulling on post - right onto the anchor - locking, pass pointing just a bit into the anchor, and done.
And at the end of the day, it's only 5 seconds, but for the interest of knot stability, you can change your post for at least one more knot. Is someone counting to 5 seconds in the background? Push down, pull, pull the other way, pass point, lock, done.
At this point, we’ll cut our sutures, and that's our repair.