Clinical Adoption of Modern Transosseous Repair

So, um, I wanted to just cover sort of my party line.

Um, for

Recommended steps for someone who's never done it before just to be safe and, and kind of help out with, with the concerns of suture management and so forth.

We, we covered this last time but just quickly to reiterate the cost ceiling that we were, we can do SCRs with graphs and, and biologics and bring them in at lower cost, less Pain, better MRI healing characteristics, better vascularity uh by Ultrasound, superior footprint reconstruction through this transosseous cirlage effect which, which is what the uh transosseous equivalent is chasing.

This load sharing concept. Um, and, uh,

So forth. So, now, I'm a beach chair guy. Are, are, who's, who, is anyone here lateral?

Anybody on lateral.

Or we all beach chair.

Beach chair

OK. Uh, I, I know you can do it laterally, um, but probably my biggest, uh, caveat is on this, uh, uh, diagram here, having a low starting portal where you do a spinal needle straight across the tuberosity. And that way, when you go, when you go in on the, on the deltoid, you're lifting up a little bit on the deltoid, and then when you engage the medial tunnel, you're able to rotate low.

Uh, you wanna fight the deltoid on the way up and have it help you rotate down. If you go in too high like the white, uh, arrow on the anchor portal, you're gonna really struggle coming down low. So that, like anything, like anything arthroscopically, you, the wrong trajectory will just, uh, you know, give you trouble the rest of the case. So it's a lower portal placement. That's the most salient, uh, thing to remember in the beginning. We clean out the bursa a little bit in the beginning.

And uh we make our medial portals, uh, all or made medial holes uh through the medial all portal all at the same time. We place the uh uh tunneler inverted and we pop through, so we use the hook of the tunneler to pop through the subdeltoid fascia and, and, and, and not sort of push it in or try to open up the fascia to create more swelling. We sort of rotate and pop it through and we use the tip of that instrument as a penetrating device.

If you see on the top right, uh, diagram, the red square, the, uh, and the blue square, about 60% of the, uh, you know, of the humerus, subscap, supraspinatus, and the, the, the GT can be the, all of the lesser tuberosity can be targeted through the anteriorlateral portal. And if I'm gonna put like a big three tunnel or a posterior portal in, we use that posterolateral portal. So those are the tunnels uh in diagram, uh, right there.

And you, you can see this is a real case. One of the Other principles that I espouse is topographic suture management. So I use these little clips that Tensor has available, uh, and such that they're, they're, they're statically clipped to the COA and then they're dynamically clipped, so they're allowing the suture to slide on those, uh, uh, drape clips up, up on the superior aspect of the picture.

And so this, uh basically what's happening on the outside of the patient is happening on the inside. So just so you can keep your bundles, your suture groups, your, your uh triplets uh separated. And then I strongly recommend this exclusion of the sutures with a cannula. And once you do this, it's exactly like anchors and there's really no difference to passing the sutures and then you can find your sutures and tie them through the, through the cannula really easily. So

Those two concepts, topographic suture management and, and using the cannula to exclude the inferior sutures, and you're basically in Business.

Um, early patterns, you know, we have a lot of guys that are kind of scared to, or seem scared to start using it. They're looking for the perfect case. You really don't have to do that. The way I learned in the bottom left diagram, the, the X's with circles are, are representative of anchors is to go ahead and do your transosse equivalent and put a tunnel between it and just use it for extra surface area compression. You can work around your tunnels and the, your anchors in the beginning and as, as while you're adopting. So,

And then in these, uh, in the early phases, I, I recommend, you know, simple sutures like the top-right diagram. Uh I do a lot of Mason Allen sutures and arthroscopically, in these, you know, suture grasping uh constructs. And uh here on the bottom right is a published literature showing already back in '07, you know, tunnels around anchors and that's, that's a 500 Newton construct right there. So there's no question that

Uh, you know, that's been done before, uh, with open or many open, uh, repairs.

Um, this two-tunnel technique is what I prefer for, for a single tendon like supraspinatus, either an Xbox all suture on the left or the true transosseous hybrid which you see in the cartoon in the bottom right, uh, and diagrammed there that's described in arthroscopy techniques. And this is the hybrid that I refer to that's a self-reinforcing construct. It eliminates anchors from the healing zone. It eliminates the type 2 failure. It still has the same Pain reduction.

Uh, and it satisfies the two major concerns that we have from surgeons. This is why we designed it about soft bone and knot tied. So, uh, you have a second chance at tensioning and you have a cortical, uh, support with a, with a knotless anchor. So in theory that, that should address surgeons' concerns about these issues. Now for big tears, you can repair almost any size tear with 3 tunnels. So I call that a double box.

Uh, and so I don't do the crossing sutures usually on 3 tunnels or above, you know, 4 or 5 tunnels even. I, if I'm bridging tunnels, I just keep it simple with a box or do simple sutures. Uh, although you can do that, you have to put in extra sutures and think ahead. So, and then on the right is a double box 3 tunnel example of the true transosseous hybrid where I'm using two anchors laterally.

Uh, but we're getting 6 fixation points medially, so there's 8 fixation points. So I'm constantly doing 9, 10, you know, 12 fixation points by methods like these, and just, and getting extremely strong, you know, repair constructs. As I mentioned before, I love doing the subscap because it's, it's so easy to do, to do a simple uh sutures under the straps, under the strap muscles. You don't have to pass as many sutures. The bone in the biceps groove is always hard.

And, uh, you know, we can tin of these and do the, do the subgap at the same time there.

And uh here's, here's the, the moving picture is a single tunnel partial like a pasta that's Mason Allen sutures. You see how good that looks. It's really hard to do that with, with anchors with a single anchor. That's a single tunnel with a single anchor, you couldn't make it look that good. So that's just the small supra or the pasta repair. Um, here's a single tendon supraspinatus. Here's an Xbox all transosseous and we've done a racking hitch ahead of that.

So there's another little technique that, a little tip that I would say for uh speed is the racking hitch. Super strong, uh, uh, great way to reduce the tendon and reduce dog ears, uh, at the end of your fixation. Here's a double box with uh suture tapes in it for a massive tear and you see we get this excellent footprint reconstruction even with just simple sutures there, um, and the tapes, uh, provide excellent, uh, surface area compression.

Here is the true transosseous hybrid with a double box. You, you, so it's a lot of sutures. It, it looks like, you know, multiple anchors, but it's not. And the, here's the, the biceps tenodesis technique I use with, here's a, here's a true transosseous hybrid. You see 5 fixation points there, 1 anchor, uh, and adjacent to it, you will see the tran the transosseous biceps. You can see it on MRI to the left.

And there we are arthroscopically, and you can see the cosmetic result of the portals.

Um, if there's people on the, on the webinar that have never seen the true transosseous, this is, this is what it looks like arthroscopically, uh, true transosseous hybrid, uh, and again, this is a step-down for surgeons. It's sort of like going from open to mini-open to arthroscopic. Uh, we're trying to give people the confidence to, uh, to transition and embrace it. And here's what it looks like arthroscopically. I mean, it looks exactly like what you would think would be a transosseous equivalent, except it's not transosseous equivalent, it's true transosseous.

The whole point of the transosseous equivalent is to actually try to keep up with what the true transosseous is doing, the cirlage effect and these multiple fixation points.

So you can get some really bomber repairs using these hybrid constructs as you can see. Um, I, my biceps technique involves a lot of weave techniques as you can see in these, uh, top, top pictures. You can really circlage. I prefer to circageage when it's a really small diameter tendon, Multiple cirlages, I think, uh, holds better and since I've started doing this, I've basically had zero failures of this. I used to have failures all the time with interference screws.

And you can see we can perform arthroscopic running crackow type sutures and you know the bone is strong enough to do that. Um, you can, you can do that before your, your tenodesis, uh, went in situ, and it's really easy. Uh, and you can really control that. Um, so I don't exteriorize the tendon. I just do it all basically in situ.

Um,

So, uh, that's just a quick run through, um, of the way I do it in a, in a couple of simple tips or tricks.