Flying Swan Arthroscopic Labral Repair using a Tensioned Suture Bridge Construct

SHOULDER TECHNIQUE GUIDE Flying Swan Arthroscopic Labral Repair using a Tensioned Suture Bridge Construct Andrew L. Wallace, MFSEM PhD FRCS FRACS Susan Alexander, MSc PhD FRCS KNEE HIP SHOULDER EXTREMITIES

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As described by: Andrew L. Wallace, MFSEM PhD FRCS FRACS Fortius Clinic, London and Susan Alexander, MSc PhD FRCS Royal Orthopaedic Hospital, Stanmore, London SHOULDER TECHNIQUE GUIDE 00557-1-01 3

INTRODUCTION Arthroscopic anterior labral repair is a well-established procedure and has been shown to be superior to non-operative treatment, especially for young male patients with traumatic instability of the shoulder 1. Although the Bankart lesion (detachment of the labrum from the anterior glenoid margin) is regarded as the essential lesion of instability, and is evident in the vast majority of cases 2, it is recognized that there is a spectrum of other pathological lesions of the soft tissues of the shoulder, including superior labral tears (SLAP lesions), humeral avulsion of the glenohumeral ligaments (HAGL lesions) and the anterior labroligamentous periosteal sleeve avulsion (ALPSA lesions) 2, 3. In the ALPSA lesion, the entire capsulolabral complex becomes detached from its insertion and heals more medially on the anterior aspect of the glenoid neck, exposing the underlying bone 4. Recently, studies have revealed that the presence of an ALPSA lesion is more common in younger patients (<25 years) and is associated with a higher frequency of preoperative dislocation episodes and a higher rate of recurrence following arthroscopic surgery 5,6. Although the aetiology of ALPSA lesions is not yet clear, the high recurrence rate after surgery may reflect the relative lack of a periosteal hinge along the glenoid neck. In simple terms, when a Bankart lesion is reattached with suture anchors along the anterior glenoid margin, the intact periosteum serves to provide a wide footprint of contact between the soft tissue and bone for biological healing to occur (Figure 1). However during mobilisation of an ALPSA lesion, it is evident that the periosteal hinge is usually absent, or collapsed and deficient. As a result, labral repair with suture anchors is dependent on rim fixation over a narrower and smaller surface area adjacent to the articular margin (Figure 2). The reduction in surface area for healing of soft tissue to bone may, in part, explain the higher recurrence rates after patients return to competitive sport. Figure 1 Figure 2 Double-row suture anchor repair (similar in concept to contemporary arthroscopic methods of rotator cuff repair) has been proposed as a possible solution to improve the footprint of healing along the glenoid neck 7, but may be difficult to achieve within the confined space of the glenohumeral joint. We have developed a novel technique, deploying the BIORAPTOR Knotless Suture Anchor that facilitates a tensioned suture bridge between anchors that improves fixation of the labrum and contact of tissue to bone and may address this problem. 4 SHOULDER TECHNIQUE GUIDE 00557-1-01

SURGICAL TECHNIQUE PATIENT PREPARATION AND PORTAL PLACEMENT The surgeon can easily use the Flying Swan technique in both the beach chair and lateral decubitus positions. Place the patient on the operating table in a beach chair position with the arm draped freely. Assess translation of the glenohumeral joint in different positions of arm abduction and rotation to determine the degree and direction of instability and the presence of an engaging Hill-Sachs lesion. Insert the arthroscope into the glenohumeral joint via a standard posterior viewing portal. Create an anterior working portal over the superior edge of the subscapularis tendon as laterally as possible. Insert an 8.5 mm x 72 mm CLEAR-TRAC COMPLETE cannula and introduce a probe to assess the integrity of the labrum. Inspect the entire joint thoroughly to exclude associated superior or posterior labral lesions, HAGL lesions, chondral defects or cuff tears. Relative contraindications to this technique include an inverted pear sign, indicative of inferior glenoid bone deficiency, and a Hill-Sachs lesion that engages with the anterior glenoid rim upon abduction of the arm 8. STEP 1 STEP 2 PREPARATION OF THE TISSUE Create an additional antero-superior working portal superiorly in the rotator interval and insert a 7 mm x 72 mm CLEAR-TRAC COMPLETE cannula. Using a sharp periosteal elevator, mobilise the entire capsulolabral complex medially from the base of the glenoid neck. Take care to adequately release all capsular adhesions so the fibres of the underlying subscapularis muscle can be visualised. Next, abrade the bony surface of the exposed anterior glenoid neck to a bleeding surface using a soft tissue shaver or a bony burr, such as the Smith & Nephew DYONICS SYNOVATOR PLATINUM 4.5 mm Blade. DRILLING Insert a BIORAPTOR Knotless 2.9 mm flat-tipped drill bit through the Crown Tip drill guide via the anterior portal. Drill holes 3 mm onto the glenoid face at 1, 3 and 5 o clock. SHOULDER TECHNIQUE GUIDE 00557-1-01 5

STEP 3 STEP 4 SUTURE-PASSING Insert the ACCU-PASS 45 Left Curve (for a Left Shoulder) or Right Curve (for a Right Shoulder) Suture Shuttle down the inferior cannula and through the labrum and capsule at the 5 o clock position. Advance the monofilament suture loop into the joint space. Use a grasper to retrieve the monofilament suture loop through the superior cannula. Remove the ACCU-PASS suture shuttle, leaving the monofilament suture tails exiting from the inferior cannula. Pass one end of an ULTRABRAID suture through the monofilament suture loop and shuttle the ULTRABRAID suture through the labrum by pulling on the tail ends of the monofilament suture loop through the inferior cannula. Retrieve the other limb of the ULTRABRAID suture through the inferior cannula using a suture manipulator, so that both suture limbs exit the inferior cannula. LOADING THE BIORAPTOR KNOTLESS ANCHOR Load the two free ends of the ULTRABRAID suture into the eyelet of the BIORAPTOR Knotless suture anchor. This anchor, fabricated from poly ether ether ketone PEEK-OPTIMA, is designed to lock the sutures in the eyelet by deployment of a small screw located in the body of the anchor. This allows the surgeon to set the desired tension on the repair, independent of anchor depth. While holding the anchor handle, push the suture threader tab forward to release the suture threader loop. Thread the free ends of the suture through the suturethreading loop. Remove the suture threader tab from the shaft of the insertion device, and pull to feed the sutures through the anchor eyelet. Note: the green retention suture is used to prevent disengagement of the anchor prior to deployment within the bone. 6 SHOULDER TECHNIQUE GUIDE 00557-1-01

STEP 5 STEP 6 INSERTING THE ANCHOR Advance the loaded suture anchor into the inferior cannula. Without tensioning the sutures at this stage, advance the anchor to the prepared bone site. Orient the anchor such that the free limb sutures entering the anchor are facing the articular cartilage. Ensure that the sutures are not twisted around the anchor. Note: Ensure that the anchor is aligned with the drilled hole to achieve proper implantation. LOCKING SUTURE & COMPLETING 5 O CLOCK ANCHOR DEPLOYMENT Establish and maintain axial alignment of the suture anchor with the prepared insertion site. Place the tip of the anchor into the prepared hole. Use a mallet to tap the inserter handle until the laser mark is flush with the cortical bone. This places the suture anchor approximately 2 3 mm below the bone surface. Unhook both ends of the green retention suture from the cleats on the inserter handle. Pull one end to remove the retention suture from the handle and discard. The retention suture must be removed prior to applying tension. Once satisfactory tensioning of the suture limbs is achieved, maintain this tension by hooking the sutures into the cleats on the inserter handle. Turn the torque limiting knob clockwise, engaging the screw and clamping the sutures in the apex of the anchor. Several clicks should be heard, confirming that the suture is locked. Unhook the suture limbs from the cleats on the inserter handle. Turn the torque limiting knob a quarter turn anticlockwise and use a mallet to disengage the inserter from the anchor. SHOULDER TECHNIQUE GUIDE 00557-1-01 7

STEP 7 STEP 8 CUTTING 1 STRAND OF ULTRABRAID & PREPARING 1 O CLOCK POSITION Cut only one of the blue suture limbs using the Smith & Nephew Flush Suture Cutter, retrieve the remaining blue suture limb and temporarily park it in the superior portal. Repeat Steps 3 to 6 with an ULTRABRAID COBRAID-blue or COBRAID-black (striped suture), in order to deploy a second BIORAPTOR Knotless suture anchor at the 1 o clock position. PASSING SUTURES BACK THROUGH LABRUM AT 1 AND 5 O CLOCK Using an ACCU-PASS Crescent suture shuttle, penetrate the repaired labrum, immediately adjacent and superior to the 5 o clock anchor. Shuttle the monofilament loop through the labrum and retrieve from the superior portal using a suture manipulator. Reinsert the suture manipulator through the superior portal and correctly identify and retrieve the remaining blue suture limb from the 5 o clock anchor. Outside the joint, pass the blue ULTRABRAID through the monofilament loop and shuttle through the labrum by pulling on the tails of the monofilament loop, via the inferior cannula. Repeat this process for the COBRAID suture from the 1 o clock anchor. 8 SHOULDER TECHNIQUE GUIDE 00557-1-01

STEP 9 STEP 10 PASSING 1 & 5 O CLOCK SUTURES BACK THROUGH LABRUM AT 3 O CLOCK POSITION Use the ACCU-PASS Crescent to penetrate the capsule medial to the labrum opposite the 3 o clock anchor. Reverse the monofilament suture loop so that the tails are exiting the tip of the ACCU-PASS Crescent. Retrieve the tails of the monofilament loop through the superior cannula. LOADING THE 2 ULTRABRAID SUTURES INTO THE 3 O CLOCK BIORAPTOR KNOTLESS Pass the two sutures through the eyelet of the third BIORAPTOR Knotless anchor, as in STEP 4. Insert the BIORAPTOR Knotless anchor into the 3 o clock drill hole. Outside the joint, pass the blue and striped suture limbs through the monofilament loop and shuttle through the labrum by pulling on the monofilament tails exiting the superior cannula, so that the ULTRABRAID suture tails are passing from the capsular to the glenoid side of the labrum. Using a suture maniputor, the blue and striped suture limbs are then retrieved back through the inferior portal. SHOULDER TECHNIQUE GUIDE 00557-1-01 9

STEP 11 When viewed from the posterior portal a good bumper of labral tissue should be evident and when the arm is moved into 30 abduction, additional external rotation results in reconstitution of the hammock effect of the inferior glenohumeral ligament. TENSION REPAIR AND LOCK 3 O CLOCK BIORAPTOR KNOTLESS Tension the suture limbs from the 1 and 5 o clock anchors by traction on the suture ends. Once satisfactory tensioning of the resulting suture bridge is completed, turn the torque limiting knob on the end of the insertion device clockwise to engage the internal screw and lock the sutures in the anchor eyelet. The insertion device is removed and the suture ends are cut flush with the labrum, completing the repair. When viewed from the inferior portal the tensioned suture bridge between the anchor sites can be clearly visualised, the two limbs of the repair being reminiscent of a swan in flight. 10 SHOULDER TECHNIQUE GUIDE 00557-1-01

ORDERING INFORMATION To order the instruments used in this technique guide, contact an authorised Smith & Nephew representative. Prior to performing this technique, consult the Instructions for Use documentation provided with individual components including indications, contraindications, warnings, cautions, and instructions. Reference # Description Reference # Description Suture Anchors 72202403 BIORAPTOR Knotless Suture Anchor (Shoulder) Suture 72202965 ULTRABRAID II, #2 Blue Suture 38 (box of 10) 72200887 ULTRABRAID #2 COBRAID suture, 38, single pack, sterile (box of 10) 72201361 ACCU-PASS monofilament, size #1, single pack, sterile (box of 10) ACCU-PASS Suture Shuttles 7210423 45º, left, sterile 7210424 45º, right, sterile 7210427 Crescent, sterile 7210425 45º, upbend, sterile 7210426 Straight, sterile 72200419 70º, upbend, sterile Disposable Burrs, Disposable Blades, Disposable Cannula, and Reusable Obturators 72203523 4.5 mm DYONICS PLATINUM SYNOVATOR 72203524 5.5 mm DYONICS PLATINUM SYNOVATOR 7209335 4.5 mm shielded burr, box of 6, sterile 72200903 8.5 mm x 72 mm Threaded Cannula, with disposable obturator, green, box of 10, sterile 72200902 CLEAR-TRAC COMPLETE Threaded Cannula, 8.5 mm x 90 mm, with disposable obturator, box of 10, sterile 72200905 7.0 mm x 72 mm Threaded Cannula, with disposable obturator, grey, box of 10, sterile 72200911 CLEAR-TRAC COMPLETE Reusable Obturator, 8.5 mm x 72 mm, (4.3 mm cannulation) 72200912 CLEAR-TRAC COMPLETE Reusable Obturator, 8.5 mm x 72 mm, (1.5 mm cannulation) 72200425 CLEAR-TRAC FLEXIBLE Threaded Cannula, 8.0 mm x 72 mm, with disposable obturator, box of 10, sterile 72200900 CLEAR-TRAC COMPLETE Reusable Obturator, 8.0 mm x 72 mm, (4.3 mm Cannulation) 3801 Switching Stick, 4.3 mm, not cannulated (13 long) ELITE PREMIUM II Shoulder Arthroscopy System 7209494 ELITE PREMIUM Suture Loop Vertical Grasper, blue handle 72201181 ELITE PREMIUM Combination Grasper, red handle 72201180 ELITE PREMIUM Alligator Locking Grasper, green handle 7209496 ARTHRO-PIERCE Instrument, straight 7209497 ARTHRO-PIERCE Instrument, 45º right 7209498 ARTHRO-PIERCE Instrument, 45º left 7209499 ARTHRO-PIERCE Instrument, 35º up 7211020 ELITE PASS PREMIUM Suture Shuttle with Ratchet 72203053 Flush suture cutter 72201659 ELITE PREMIUM Hook Knife 72201660 ELITE PREMIUM Bankart Rasp 72201661 ELITE PREMIUM Knife Rasp 72201915 3.8 mm tapered awl 72201177 ELITE PREMIUM Crochet Hook 7209134 ELITE Calibrated Probe 72201212 ELITE PREMIUM Full Loop Knot Manipulator, silver handle (qty 2) 72201186 ARTHRO-PIERCE Instrument, curved left, Inline handle 72201187 ARTHRO-PIERCE Instrument, curved right, Inline handle 72202042 Shoulder arthroscopy sterilization tray and lid SHOULDER TECHNIQUE GUIDE 00557-1-01 11

References 1. Primary arthroscopic stabilization for a first-time anterior dislocation of the shoulder: a randomized, double-blind trial. Robinson CM, Jenkins PJ, White TO, Ker A, Will E. J Bone Joint Surg Am. 2008 90:708-21 2. Prevalence comparison of accompanying lesions between primary and recurrent anterior dislocation in the shoulder. Kim D-S, Yoon Y-S, Yi CH. Am J Sports Med 2010 38: 2071-2076 3. A comparison of the spectrum of intra-articular lesions in acute and chronic anterior shoulder instability. Yiannakopoulos CK, Mataragas E, Antonogiannakis E. Arthroscopy 2007 23: 985-990 4. The anterior labroligamentous periosteal sleeve avulsion lesion: a cause of anterior instability of the shoulder. Neviaser TJ. Arthroscopy. 1993 9:17-21. 5. Results of arthroscopic capsulolabral repair: Bankart lesion versus anterior labroligamentous periosteal sleeve avulsion lesion. Ozbaydar M, Elhassan B, Diller D, Massimini D, Higgins LD, Warner JJP. Arthroscopy 2008 24: 1277-1283 6. Anterior labroligamentous periosteal sleeve avulsion lesion in arthroscopic capsulolabral repair for anterior shoulder instability. Lee BG, Cho NS, Rhee YG. Knee Surg Sports Traumatol Arthrosc 2011 19: 1563-1569 7. Evaluation of glenoid capsulolabral complex insertional anatomy and restoration with singe- and double-row capsulolabral repairs. Ahmad CS, Galano GJ, Vorys GC, Covey AS, Gardner TR, Levine WN. J Shoulder Elbow Surg. 2009 18:948-54 8. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Burkhart SS, De Beer JF. Arthroscopy. 2000 16: 677-94. CAUTION: U.S. Federal law restricts these devices to sale by or on the order of a physician. Endoscopy Smith & Nephew, Inc. Andover, MA 01810 USA www.smith-nephew.com +1 978 749 1000 +1 978 749 1108 Fax +1 800 343 5717 U.S. Customer Service Courtesy of Smith & Nephew, Inc., Endoscopy Division Trademark of Smith & Nephew, registered U.S. Patent & Trademark Office. 2011 Smith & Nephew, Inc. All rights reserved. 06/2013 00557-1-01