Final Roundtable Discussion

Speaker 1Um, so any questions from the audience? I haven't seen a whole lot of, uh,

Speaker 1Um,

Speaker 1Chats here, but I would encourage you, uh, to, uh, to, uh, ask questions if you have them. I know we're a little bit over on, uh, on time here. Is there anything the panel would like to add before we close? Uh, anything we didn't cover, anything you think would help your colleagues adopt or some problem that you encountered, you know, when you were trying to adopt these techniques at first that you were surprised by that we could mention?

Speaker 2Just one real quick comment I had about your, the racking uh hitch suture, which is, is basically you put the tunnel and then you use the shuttle suture as your repair suture. So, um.

Speaker 2That, that's super easy and that might be a really easy way to start with some partial. I love doing that for those partial split, the really small partial split subcap tears. Um, I'll just literally repair it with one simple stitch, the repair stitch, so it makes it even easier. You don't have to shuttle sutures, um.

Speaker 2And and yeah, that, that racking, I need to make like an animation of how to tie that stitch for people who don't know. It's like it's the awesomest stitch, the easiest stitch in the world. I mean you can use it for all sorts of things like even, you know, combinated clavicle Fracture pieces, like putting those together, like all all sorts of things, uses of that. So anyway, just

Speaker 2Just that comment.

Speaker 1Yeah, and there's also a little trick for speed that was written up, uh, I believe in JSES by BS BUESS at all back in like 2018, 2019.

Speaker 1Uh, of passing the doubled, uh, passing stitch, just take your integrated pass or pass that through the cuff and then pull three sutures through the cuff and bone simultaneously. So it eliminates all your passing steps, right? And then you could do that twice and you have 6 sutures passed through the cuff. So then you can weave, you can, you can weave those into a transosseous Xbox like you normally would.

Speaker 1And it saves a ton of steps. And this is, I think Doctor Brodigan was alluding to this earlier. A lot of people who, who think that Transosse is gonna be a lot more time-inefficient, either haven't done it or haven't thought it through and that you're saving steps by passing simple sutures instead of mattress sutures. And then, you know, think about the transosseous equivalent repairs where people say,

Speaker 1Well, it's knotless because I put in a knotless anchor as the last step, and it's like, but you tied the medial knots.

Speaker 1And they were mattress passes, right? So they're like, like you did tie knots and you did multiple mattress passes.

Speaker 1Whereas with the transosseous repair, you're passing simples and then if you just tie those, you're tying the same amount of suture as you would with the transosseous equivalent, but you're done, you know, and you tie your knots low and lateral. So Uma had brought that up laterally or, uh, before I, I, I use my post uh laterally to keep the knots off the top of the cuff. Not that it really matters, but just as a style point or as a cosmetic point, I just like to keep them low so it's nice and smooth and it looks just like a transosseous.

Speaker 1Equivalent knotless type repair. So, again, there's such a plurality of techniques here that it's almost like a Pandora's box, a bunch of, of new things to do and once you get into it, it is, it is so fun to uh be able to differentiate these new techniques and, and, uh, optimize for whatever you feel like optimizing for at the time, whether it's cost or time or fixation points.

Speaker 1You know, given the case, you can, you can, you can do it all with unlimited fixation points. So.

Speaker 1Uh, that was, that was, that was one of the things that was a pleasant surprise to me, uh,

Speaker 3uh,

Speaker 1in addition to the Pain, Pain relief that we've all been talking about.

Speaker 3Right, that's one thing

Speaker 3I wanted to add to your, your hybrid technique is that, I mean, if there's a dog ear, if there's part of the cup that you feel like you didn't capture with your tunnels, you can throw an extra suture in and incorporate that into that far lateral tunnel with those Other, you know, knots, um, that, you know, for help with compression. So I think it, it really gives you that added, you know, security blanket, uh, for more fixation points. I mean, not just using the suture you've already passed, but additional suture if you need to.

Speaker 3Um, you know, once you're done tying things down, maybe the cup didn't come exactly how you wanted it to sit. Maybe there's a, a, a flat, you know, posterior that you want to capture. Um, I just think it's just, it is, gives you some more versatility with the repair.

Speaker 1Have you ever, has anyone ever tunneled straight through the cuff, just through a poke hole with a, with a blade? Yeah, for

Speaker 4actually for the, uh, the pasta type repair, you know, an articular sided repair. I actually like placing anchors and tunnels from the joint, you know, viewing from inside the joint, uh, posteriorly. You can really see your articular margin, uh, and you can just kind of poke it through and, you know, pass your one tunnel and then the suture, one of your sutures already there. You can pass the Other ones and then just go to the subacromial space and tie.

Speaker 4And you, you're not at risk for over-restraining like an articular-sided tear by the suture passage. So that's, that's always nice. I would actually suggest starting with a bigger tear. It's easier to see everything in the tuberosity, uh, you know, with a much larger tear. It's actually a little bit more difficult if you're, have one of those little crescent tears that you're trying to look inside and outside with. And if you're a little uncomfortable with it at first, uh, just start with a bigger tear. You can see the whole tuberosity and, you know, work your way down to the smaller tears.

Speaker 1Yeah, I agree, and it's, and even if you've never done it before, uh, uh, on a big tear, you know, a 29 hole in the bone does nothing to prevent and, you know, the placement of an anchor and even if you can't, let's say you can't get the, let's say the portal's off and you can't get the tunnel in or let's say the bone is off and you don't like it, or let's say you accidentally unload the suture.

Speaker 1What happens? Nothing. You can just put another tunnel in the exact same tunnel or you can put an anchor in the exact same tunnel and the diameter mismatch makes the anchor even work better, you know, so.

Speaker 1That's one of the things about early adoption is the, the ramifications to unloading a tunnel are far less than unloading a suture anchor where you put a suture anchor in. If you unload that, you've burned your fixation point, right? Like geometrically, you've just destroyed that surface area that you're trying to fix to and you can no longer use it or you know. Whereas if, if you unload a tunnel, you just tunnel through it again or put an anchor in it or, or whatever or use an existing suture to just pull 3 more sutures in.

Speaker 1There's just so many different ways you can bail yourself out of problems. It's actually way easier and less detrimental when you have failure modes with tunnels. Um,

Speaker 4yeah, I agree. I mean, it's, it hasn't, it's not super challenging to, um, train folks, you know, we have a fellowship program of residents and it's, it's stuff that is well within range to, to learn at that stage. It's just a matter of your philosophical thinking about it, your paradigm about it.

Speaker 4But I mean, we do start with uh anchors and showing them a double row. And then a tunnel is essentially that, you know, you have your medial vertical, you know, row, and you have your lateral row. It's just a little bit more suture management, but easily achieved, you know, like you mentioned with some of your techniques or just pick some different colors and, you know, it's not hard to keep track of.

Speaker 2Yeah, that is important, you know, using different colored sutures, absolutely. That's probably another thing that can be mentioned is, uh, when you're first doing it, don't, don't put any, put 3 different stitches in your tunnel or, you know, whatever, put different stitches.

Speaker 4That was one of the questions on the Q&A like what sutures do you use? Um, I responded to it. I mix it up just with it whatever gives me a different color is fine. At the bond, people can use fiber wire. I prefer softer suture, you know, like number 2s are actually, you mostly use tapes, like a 1/4 tape, I think is perfect. Use up to like a 2.3 millimeter tape, uh, as well.

Speaker 4And one Other final, uh, technical tip, you can get your same sutures through all 4 of your tunnels, you know, or, you know, if you have 2 full tunnels, you can take sutures and run through all four, and bring them up and just do one anchor, and that's a true knotless transosseous uh type fixation without tying anything.

Speaker 4So if people are, you know, interested in not having to tie any knots, but use tunnels in one anchor, you could do it that way

Speaker 1too. Like a you with a mattress across the bone.

Speaker 4Yeah, anteriorly, it goes down into your vertical tunnel. It comes across out, and that same suture comes back around your greater tuberosity and in through your posterior tunnel and back up. So if you pass them into your cuff, now you just lay them down and you're done, you know, uh, in, in your anchor if you don't want to tie. I still like to tie.

Speaker 1And that's going against the grain perpendicularly, and that rarely cuts out that way.

Speaker 4Yeah, it can't. I mean, you'd have to cut out a massive amount of bone, you know, yeah,

Speaker 1like 2 centimeters of bone, exactly. Uh, I, I, I've almost never seen that, and, uh, I think there's a difference in the anisotropic properties of bone where it just, you know, the loading behavior is different depending on the direction. So when you're going perpendicular to the grain like that, it just doesn't cut, cut through nearly as easily. Uh, it has to be like super soft.

Speaker 1Yeah, that's a, that's a, that's a great point.

Speaker 1Um,

Speaker 1Well, that's, that's great. Uh, I think we've, we've, um, about reached the, the, uh, limit of, uh, attention span here. We've covered tons of interesting things. I think we've still got things to cover in future webinars.

Speaker 1Uh, we'll, we'll cover some allografting techniques and some, uh, advanced techniques maybe in the future. I really appreciate the attendees and the panelists. Uh, tonight it's been really fun and, and, and spontaneous and, and, uh, love the interaction of the, the small family of transosseous docs.

Speaker 1Um, and, uh, look forward to, to, uh, getting together with you guys in the future. So unless there's any, anything else anyone wants to, to, uh, contribute, I'll go ahead and conclude with that.

Speaker 1And thank you

Speaker 3so much, enjoyed it.

Speaker 1All right, everybody, thanks so much for attending. We'll record this and, and send it out afterwards.

Speaker 3Have a good night.

Speaker 2You too.

Speaker 1Thanks. Cool, y'all have a good night.