Suture Management by maclaren1


									                                Suture Management

A. Good suture management is a critical skill in arthroscopy shoulder surgery. It is important
   to minimize suture breakage which occurs from fraying of sutures against sharp
   instruments or edges of canulas. If sutures are entangled then repeated manipulation of
   the sutures to unentangle them leads to suture abrasion and breakage. Sutures placed
   properly are more likely to slide well and result in more knot and loop security. Vast
   amounts of time can be saved when these techniques are mastered. This time results in
   decreased soft tissue swelling and better results.
B. Basic Concepts:
   1. Triangulation
   2. Suture marker
   3. Portal issues
   4. Suture or anchor first techniques
   5. Concept of inner and outer limbs
C. Triangulation technique essential for cannula placement, suture marker and suture
   retrieval. A technique that will save time and is beneficial in large people is the
   1. Visualize desired entry site with scope
   2. Externally visualize from needle entry site
   3. While looking at shoulder direct toward forward tip of scope
   4. Confirm on scope monitor

D. Suture marker technique
   1. Correlate joint and bursal path.
   2. Useful for partial RCT
   3. 18G Spinal needle
   4. Monofilament suture
   5. Place suture outside cannula

                                                                     E.     Correlation of
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                 Bursa                               Joint

F. Suture management
   1. Frequently facilitated by 3rd portal
      a. 1 Scope, 2 instruments, 3 retrieval devices
   2. Tie knots from portal from which anchors placed (unless anchor was inserted
   3. Never place knot down canulla with more than 1 suture set

G. Creating portals
   1. Inside out
   2. Outside in

H. Suture first fixation: Using as an example Type II SLAP repair
   1. Deride labrum
   2. Prepare bony bed
   3. Drill hole
   4. Pass suture thru labrum
   5. Pass anchor
   6. Tie knot

   * With suture first technique, the anchor needs to be loaded on the "inside" suture limb
     (not through tissue) so it can be slid down cannula into bone. In contrast, the knot needs
     to slide down the "outside" suture limb to cinch down the tissue firmly to the anchor in
I. Debride bony bed

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J. Drill Hole on Corner

K. Suture through Labrum and Insert Anchor

L. "Anchor First" Fixation: Using as an example a Type II SLAP
   1. Prepare bony bed
   2. Drill hole & insert anchor
   3. Retrieve suture through tissue
   4. Tie knots

                                Anchor on Corner

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                            Grasp suture                                              from the

                                      Tie a knot

M. Knotless Anchor
   Knotless anchors are well suited for the lateral row in dual row rotator cuff repairs. They
   tend to roll the edges of the cuff down so that the cuff edges don’t get caught on the
   lateral edge of the acromion and there are no lateral knots to get caught either.

   When tying knots for Bankart repair, it is possible to engage the labral tissue and roll it
   up onto the glenoid rim creating a soft tissue buttress. This is much more difficult with
   the knotless design. The length of the loop in the anchor is fixed and therefore a proper
   bite of tissue must be taken so that the proper tension will be applied to the suture when
   the anchor is seated to the proper depth. Too big a bite will result in difficulty in inserting
   the anchor subcortically without cutting through the tissue and too small of a bite will
   result in a loose repair.

N. Dual or Triple Suture Anchor
   1. Screw in
   2. Rotator cuff
   3. Different colors
   4. Stress distributed over broader area
   5. Necessitate a third cannula to park one or both sets of sutures (Neviaser portal)
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O. Super Sutures
   One of the long standing challenges of arthroscopic stabilization and rotator cuff repair
   procedures has been suture breakage. The newest generation of sutures has greatly
   reduced this problem. Each company has its variation in this area. All tend to be much
   stiffer than Ethilbond or braided polyester and suture ends are more proud. All require
   specialized suture cutters to cut the knots. Make sure that you have the proper cutters
   before you use these sutures.

P. Blind Knot Cutter
   1. Guillotine design
   2. Prevents knot cut out
   3. Works well when visualization poor
   4. Rotator interval closure

Q. Suture Shuttle
   Braided suture is too flexible to feed it through a suture hook device and therefore some
   sort of suture shuttle is passed through the suture hook first and used to retrieve the
   braided suture through the tissue. This can be a commercial suture shuttle (Linvatec) or
   there are various substitutes. Doubled over #2-0 prolene is an easy substitute but attention
   must be paid to the direction that the suture is passed. An easier way is to pass a #1 PDS
   suture through the tissue first and then tie the appropriate end around the braided suture
   with a simple knot. Various companies make devices such as the Arthrex bannana device
   which has a doubled nitinol wire in it.
       1. Doubled over #2-0 prolene
       2. Simple #1 PDS
       3. Disposable versions

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