First Roundtable Discussion

Speaker 1The usual argument I hear is, uh, what about the suture cutout of a tunnel? Cause I think, you know, we've all experienced it and, um, more than just learning it, if, even if they accept it, uh, I think there's a sort of over, uh, concern about suture cutouts. So I would like to hear, you know, from the panel, how frequent is it for them, how do they manage it, how do they avoid it, and things like that, I think would be helpful and reassuring to people first adopting it.

Speaker 2Yeah, um, that's a good question we can run through. Um, I'll say for me, you know, uh, probably 250 cuffs a year, you know, uh, maybe more, um, maybe once a year. And, uh, I, I have some slides on this, but in, in general, I think, you know, the, the osteoporosis starts if you look at the nomograms over age 75. So,

Speaker 2There's a lot of cuff repairs going on between age 40 and 75 where you just don't have the osteoporosis. And with the, the recommendations to fix smaller, younger cuffs and younger patients, you're not getting that 80-year-old female with butter bone, chronic irreparable tear that, that slices right through the bone. Well, that one gets a reverse now. So the indications have really changed.

Speaker 2And, and, and to me, that's, that's what makes it true. There's, there's some technique-specific things about tensor where we don't drill, we compact the Bone tunnels. The geometry of the Bone tunnels are, are, are rectangular. This is the anisotropic property, properties of bone that play into, to, to, uh,

Speaker 2Directional cut-through and, and so there's some technical factors there that may account for it. Also multi-fixation points, so load sharing. So I'm doing cuff repairs with 8, 1012 fixation points. So you're, you're doing so much load sharing, it's like a bed of nails, you know, you can push a balloon on it, it won't pop, unlike, you know, those super, super tight or super uh uh pressure spikes you get with like a speed bridge or something.

Speaker 2You know, so I think there's, there's a lot of reasons why we're not, I'm not seeing a lot of cut-through, uh, um.

Speaker 2Bill, uh, any thoughts on cut-through, sutures cut-through?

Speaker 3So, also very rare for me, um.

Speaker 3I, I, I do, yeah, I don't know, maybe 200 Rotator Cuff repairs a year and, and I still do use the uh

Speaker 3The arthro tunneler from time to time, mostly based on uh the availability of uh transnsos at my facilities. And I, I do notice, um, more cut-through, you know, maybe it is um because of the rectangular geometry of the transos punch. Uh, I, I honestly really don't know, but I have noticed more with the ortho tunneler.

Speaker 3Although still, even with the artal tunneler, it is quite unusual. It's quite rare for me to have to, to see a, a suture cut through and then have to deal with it. That's happened, you know, I've been in practice now for 9 years and I've had the, the experience of using the tunneller ever since I came out, um, you know, maybe twice. But it literally is a very, very rare occurrence that it's a problem that I have to, to deal with Other than

Speaker 3Um, you know, using a tape instead of a suture or something like that.

Speaker 2And, and so obviously you can use tapes to decrease plastic deformation. What is your go to bailout if you think it is a problem? If you worry about it, how do you bail it out?

Speaker 3So then I, I put a tunnel in a different location or, um, you know, given the fact that I do still have access to arthro tunneler, uh, we have some leftover tunnel protectors. So, uh, very rarely, again, maybe once a year at most.

Speaker 3Um, I'll take a, a tunnel protector and put it in there, so that, that's my, um, ultimate bailout.

Speaker 2That's interesting. My bailout with the true Trans osseous hybrid technique, I, I've been developing this hybrid technique trying to step surgeons in who are learning into the fact that you can use anchors with tunnels. They're not mutually exclusive, they're synergistic. So if you think the bone's really soft, well, the next question is, do you think an anchor would work or would it pull out? Because you have guys that are bailing out of anchor pullouts with tunnels through the hole, right? So,

Speaker 2Uh, how are we looking at it? Are tunnels the salvage for soft bone, or are they, are they a problem with soft bone? That's what I'm having trouble.

Speaker 2Uh, understanding because a lot of surgeons want to use the tunneller, for instance, in a, in a setting of a, of a bone void or a, or a cyst, you know, where they're worried about anchor pullout. My, my go to bailout is a lateral row knotless anchor that you can essentially just grab all of your sutures, fix them down low and lateral on the diaphysis where there's usually hard bone, very low in the diaphysis, get past that soft metaphyseal zone. You still have fixation at the healing zone.

Speaker 2And no inert material there and you could get a great backup and it's, you know, it's triple row, uh, and so for me that saves a lot of time and it's easy. Uh,

Speaker 1what are you guys

Speaker 1doing to prevent it? That's obviously a low rate and I agree 100%. Uh, I have just as many anchor pullouts, uh, probably more than any tunnel cut through, and there's several things, you know, you can do to remove it. So I'd just like to hear what your guys' tips are on, on just preventing them in the first place, like arm position.

Speaker 1Do you, which, which of the sutures do you use as your post? How, what knots are you using? I actually prefer tapes in general, so I'll use multiple tapes anyway. And that I think protects your tunnel and lines it very well from the get-go. And obviously trying to get low on that, on the lateral side of the greater tuberosity to better bone. But what else do you guys do?

Speaker 2Uh, Doctor Brodigan, you wanna take that?

Speaker 4Yeah, I, I think it's important to, um,

Speaker 4Understand that on the top side of the greater tuberosity, you have much more area to place the tunnels as, as compared to the lateral side. They kind of converge.

Speaker 4Down on the lateral sides, so you have to be aware of that and if you use an arm holder like a spider instead of just an assistant holding the arm, you can control, uh, the rotation and change the position of the arm for each particular tunnel. You have to allow a little convergence so that the vector of the suture comes, uh, from wide to narrow, from medial to lateral. So, in understanding that, you have to be very careful about where you position the device, the tensor device.

Speaker 4For the exit point laterally. Um,

Speaker 4As long as you have the tunnel spaced out adequately on the lateral side, I really don't have cutout. If, if the tunnels converge on the lateral side, you do risk a little bit of cutout, but even if they converge a little bit on the lateral side, they're going to be divergent as they go medially. So, um, you're, you're still pretty safe with most patients. I think it's important to have your tunnels established.

Speaker 4Very, very close to the articular surface. If you, if you cheat a few millimeters laterally, you're losing some of the best bone and one of the bailouts would be to, if you have a pullout, medialize your footprint a little bit. You can take away a little bit of the articular surface, medialize your footprint, get good subchondral bone and reestablish a new tunnel. The Other thing is, is don't decorticate the greater tuberosity too aggressively. In fact, leaving some Sharpie fibers on the greater tuberosity is just fine.

Speaker 4Um, you don't have to get it down to, to bare bleeding bone. Um, you know, we have a tunnel. We have multiple tunnels. We, we're gonna get Bone Marrow through the tunnels. We, we can leave Sharpie fibers on top and that's probably much more preferential in all cases, not just the soft bone cases. And then, again, if you use simple sutures and multiple sutures, we're soft tissue surgeons, when you're tying these knots, there is touch and feel associated with it. You can't overdo it here. You have to use physiologic tension.

Speaker 4We're not going for crushing levels of tension, and you have to be mindful of ischemia if you over tension. So it's, I think it's, uh, you know, your pullout is gonna be if you're too aggressive, uh, for the most part and if you converge.

Speaker 2Yeah, that's a great, you're, you're bringing out some great points. Uh, I, you know, I've always thought that, you know, the amount of pressure that you're generating hammering in like a swivel lock, I mean, I just imagine the just the impulse of a hammer. You're, you're, you're just tightening that so, uh, tight, you know, it's, it's no wonder these type 2 failures, and I view that as an advantage as well, the tactile feel. If you have a little plastic deformation, it's just like sewing a capsule, you know, when you're doing a capsule lication.

Speaker 2I, I also agree with, you know, so there's some Japanese studies showing that, that it is actually better healing to leave the fibers intact because you're not reconstituting those. They're already established. You, you're, you're just scarring them in, you know, even if it is Bone Marrow, even with the studies showing Bone Marrow, you know, improves healing. Um, I decorticate laterally. There's a great point.

Speaker 2Now, Mark Mark Lazarus brought up this point on the last webinar that if, if you have convergence medially, even if you broke through, like if you had two anchors converge, that would be a problem because your, your, your anchors, you know, would be stacked or they would be in, inner, the diameter mismatch would not be great enough and they would pull out. When you have tunnels converging immediately, it really doesn't matter as long as you diverge laterally. So, you could have a trough immediately and tunnel right through it.

Speaker 2So what I do is use the all, uh, just by tactile feel. If I can push the all in 2.9 millimeter all as opposed to a 45 or 5.5 anchor, if, if I can push that in by hand, I, I, I think a little bit about the bone quality. But as we know, even with, with microCTs have shown this and, and

Speaker 2You know, with uh, you know, chronic supra and acute infra tears, for instance, you'll have one area of the same patient that has soft bone, and then you have multiple Other areas that have great bone, you know, like the, like the biceps groove or, or the posterior aspect. So just because one tunnel is soft, it doesn't mean

Speaker 2You know, panic. It, you just, that's why we plan our footprint at one time. So you know which one's soft and then you can go ahead and put your, um, you know, your tapes in or whatever your backup plan is or fixed laterally with a screw or, uh, or a knotless anchor or even backup with, uh, buttons, you know, we've done that with ACL buttons and retro buttons.

Speaker 2What have you learned, Nick, about that, uh, anchor pullout or uh suture pullout? Any thoughts there?

Speaker 5Yeah, I mean,

Speaker 5my initial test, once I make the bone tunnel is, is I will pull on that passing suture just to, to make sure that it seems taut and strong. I mean, anteriorly, I, I, I, I try to get as low as possible. All the points that have been made have been very well made and um all the tips that I've have, have used.

Speaker 5From, from listening to y'all in the past and whatnot. Um, but that's just my initial thing where I'll pull in that passing suture. I make sure it's nice and strong, that the Shoulder will move with it. And, and then I'll pass the three sutures beyond that. I mean, I think the tension of the repair is important. I keep all my knots down low. Um, you know, so they're not, you know, sliding over the bone there. Um, and yeah, I, I often, yeah, I'm sorry, not often, but if need be, I'll use the hybrid technique and bring in a lateral anchor.

Speaker 5You know, if there's any sort of tissue flap or if there's any sort of thing, uh, concerning, I'll just go for, you know, third row essentially with the, um, with another anchor just to supplement it. But I haven't had any, any issues, um, at all with the, with pulled through the bone or whatnot.

Speaker 2Um, again, Doctor Brogan's talk brought up a lot of great points here about interosseous pressure and the biology of healing and the Fracture biology that's incited by cramming an anchor into a hole, right? Especially medially where you have that hard bone.

Speaker 2Um, uh, you know, and I saw a presentation with, uh, Buddy Savoie recently talking about how with the vinted, you know, the helicoil anchors were showing increased thickness of the tendon healing. We know that transosseous has literature showing better vascularity by Doppler Ultrasound and the healing phase at all the critical zones.

Speaker 2What are, what are, Uma, what is your thought on biological healing of the cuff with more physiologic, more access to Bone Marrow, less pressure?

Speaker 2Better blood flow and this whole thing of the meteor row anchor causing a lot of Pain. Do you have any thoughts as a, as a, as an academic, uh, on

Speaker 2that?

Speaker 1No, I think, uh, uh, yeah, I think Brad was 100% correct that the anchor industry has made the argument already for us. So when I do use anchors, I'll, I only use a vented type anchor where the tunnel still remains inside so you can get.

Speaker 1Direct access to the best elements, which is really the Bone Marrow. So, I, Brad mentioned PRP, but I actually agree with Brad. The, the Bone Marrow is the best. I'll actually use, uh, one of those jam sheeties and pull out Bone Marrow from the humeral head, use that as my all. I'll take about 15 to 30 cc's. And you gotta, you have to do that before you decorticate or you just get a bunch of water coming back. You have to go fairly deep. But you can get a good amount of Bone Marrow.

Speaker 1Uh, leave that on the back table. You can use that all whole as your medial tunnel or your medial, you know, placement for an anchor. Uh, but yeah, I 100% agree that the, that tunnel, uh, is your direct vent to biology, and it's just normal biology. You're not messing with it. You're not trying to spin something down and guess what the body needs at what time, uh, to get growth to go. We know it's extremely complicated.

Speaker 1What the body's doing in terms of the healing process, inflammatory process, or both, about what factors are firing at each time. I don't think we can replicate that yet with, you know, squirting, you know, PRP that's spun down with removing certain elements and guessing there yet, you know. So I prefer just Bone Marrow vents to go up to the cuff, and then I'll save some Bone Marrow and throw that on top.

Speaker 1Uh, as well, and you can I'll add that with microchanneling if you have some exposed greater tuberosity or laterally, you can kind of additionally put some additional vents, uh, on the outer side as, uh, Snyder described in crimson duvet fashion. So I believe 100% in the Bone Marrow and that's, uh, fixability.

Speaker 2And, and, and Dr. Mazaka has shown that there are good stem cells present in the, the, the proximal humerus, correct?

Speaker 1That's right, compared to iliac

Speaker 2breast, even,

Speaker 1yeah, it's, I think it's more than adequate. I'm sure. I think the calcaneus has the, the best. So if you really want, you can harvest from there, you know, a separate surgical incision with a trocar or whatever and inject that on top. But, uh, certainly the proximal humerus has a lot of stem cells as well.

Speaker 1And more than PRP.

Speaker 2Yeah, um, and, uh, since we're talking about this, uh, I, I had this up earlier. This is one of, and Doctor Lazarus talked about this. You, you don't see this with anchors. Here's the drop, uh, scope repair of the cuff, and this was read as, as a normal MRI. So that's a post-op cuff repair that looks so good on T1 that the radiologist can't tell that it's been repaired.

Speaker 2And you, I just never saw this before transosseous. You would always have that Sugaa 3 like T2 edema, you know, in the tendon where you have that overly stiff, you know, anchor point there. Um, but, um, I don't know if you guys have come across any of these yet, if they fall or if they're having Pain and you MRI them and, and it's basically like not even red as a cuff repair, but I know Lazarus has.

Speaker 2Um,

Speaker 2So, um, let me, let me do one more, uh, question to you guys. You, uh, we brought up the, the

Speaker 2Uh, you know, anchors and, and pressure, and, you know, it's interesting. I, I make the case that the, and, and Randelli has made this case before me that there's a logical progression of the industry going back to transosseous techniques and maybe they don't know it, but the industry is moving towards, you know, soft anchors. And I've even heard some of the, uh, anchor companies, you know, touting soft anchors medialy as having less Pain, and it's got to be some of the same effect.

Speaker 2Uh, but I just wonder, you know, if, if you believe that a pre-tied knot, which is what a soft anchor is, won't pull out of bone, you know, why not go to a circlage effect, tie the knot afterwards, and get a 2 for 1 Efficiency on your double, on your footprint reconstruction. Any, any thoughts on that soft anchors versus, you know, are they the same? I mean, they're the same morphologically, right? In you guys' minds, is there any difference?

Speaker 1Yeah, I'm actually concerned with there's actually some literature out about cysts forming around all Suture anchors, uh, in the glenoid and otherwise. I think it, it's probably just the amount of the ball of suture you have now there that it doesn't have the same, uh, properties, I guess, as just a single suture traversing through bone where bone just goes around it. But there is literature out now about the level of cyst formation with not just the soft tissue anchors, but obviously some of those resorbable ones that

Speaker 1are popular on the market as well. So I avoid those completely.

Speaker 2Good. Um, OK, great. Well, we covered a lot of great stuff there.