Knotless FiberTak double row cuff

This video will demonstrate case examples of doing double row rotator cuff repair with knotless soft anchors. I use a 2.6mm knotless Fibertac anchor in this case for my medial row, and then I usually take the suture limbs out to a Sulvalock anchor laterally for a knotless repair. But what's unique about this particular knotless soft tissue anchor is that there's a number 5 suture and there's a knotless mechanism in that sheath, as you can see in this up-close view. The number 5 suture can be passed through the sheath itself to create a simple stitch, but also you can pass the suture through a second anchor to create a linking mechanism between the two anchors that functions like a Chinese finger trap to create a knotless fixation between the two anchors. This technology is particularly useful because we can do this all inside a very small anchor, which is useful in cases where we have either a limited footprint or want to be minimally invasive, such as a trans-tendon repair or a remplissage. Hence the indications. My indications are posterior repair, remplissage, upper subscap tears, and double row small full thickness tears, as we'll see in these examples. First case, this is a right shoulder in a gentleman in his 40s. His biceps is intact. He has a full thickness rotator cuff repair with minimal retraction. So I've done a biceps tendinosis for subscap repair in this case. Here I place a knotless 2.6mm Fibertac anchor. Spinal needle is used as a guide and a second anchor is placed percutaneously as well. In this case, the bone socket was drilled but can also be punched. Here we see those 2.6mm knotless anchors have been impacted into place. We then go to the subacromial space and I retrieve the posterior sutures at a lateral portal. I'm going to pass a Firelink suture through the rotator cuff. The suture has a loop on one end so I can shuttle all the sutures through the rotator cuff from that posterior medial anchor. Process is then going to be repeated anteriorly, and now both set of suture limbs are passed through the rotator cuff from the anterior anchor and the posterior anchor. We inspect anteriorly and we can see there's a potential dog here. We also like to reinforce the rotator cable attachments, so I pass that FiberLink suture through the rotator cuff anteriorly. This is going to retrieve down the anterolateral portal. Now posteriorly, I'm going to take the number 5 suture and retrieve that, and then anteriorly from that anterior anchor, I'm going to retrieve the looped suture. That allows me to shuttle the number 5 suture from the posterior anchor into the sheath of the anterior anchor. This engages that knotless mechanism. But we don't want to seat the suture completely. We want to bring it down just above the rotator cuff, and then we repeat the process. The loop from the posterior anchor is used to shuttle the suture from the anterior anchor into the posterior knotless sheath. As you can see here, we're pulling up on that suture to deliver the number 5 suture into the posterior sheath, and now we've created our double mattress suture. This is the same concept we do with a medial double pulley, but in this case it's a— All those sutures are then taken out laterally. We go back and inspect in the joint, and we can see the rotator cuff is nicely opposed to the articular margin. Here we use the cannula as a guide to determine the location for a lateral anchor, and while doing this, we see that there's a potential dog ear posteriorly. So another fiber-linked suture is placed as a half racking suture. A bone socket is then created for a knotless SilverLock anchor. We're taking the fiber-linked suture anteriorly and posteriorly, as well as the two number 5 sutures from the cannula anchors out to this lateral anchor. This is a 475 biocomposite Swabloc anchor, and here you can see we have a knotless, low-profile, double-row rotator cuff repair. This is particularly nice for small tears. For larger tears, I'd use more of a traditional suture bridging technique where we have 2 anchors medially and 2 anchors laterally, but in a case like this with a small, minimally retracted tear, I think this is a good technique. This is another example Just showing again how that technique can be illustrated. This is a right shoulder in a female. See, she has a full thickness tear of the supraspinatus tendon. Small footprint here, so I placed two 2.6mm knotless Fibre-Tac anchors with that anterior anchor. We want to be sure that we don't pass the suture through the biceps tendon, so I'm inspecting there and I'm going to pass it through the rotator cuff as we showed before and then shuttle all the sutures through the tendon. Now we have both through the tendon, we've created our double mattress suture. We can use an instrument as well as we're pulling up on the anchor to tension it so that we don't create any jeopardy to the anchor. And here we see on the intra-articular view there's nice apposition again of the tendon to the articular margin. And I'll take these out to, again, a Swivelock anchor. In this case it's a 475 Peak anchor. In this older individual. This is a lady in her 60s. You can see again a low-profile knotless rotator cuff repair for a small tear with a small footprint, but which is also amenable to double-row repair given good medial to lateral mobility. Final case example, this is a left shoulder in a gentleman in his 40s. Here's his exposed footprint, again with minimal retraction. The biceps tendon is also intact in this case. As we can see here anteriorly, inspecting the subacromial space, you can see there's very minimal retraction of this full thickness tear. But because the entire footprint is exposed, I want to get complete footprint coverage, so I use a spinal needle as a guide. I place a 2.6mm knotless Fibertac anchor anteriorly here. This one I, I've placed with a punch. Now the anchor is inserted, and then the posterior anchor, that's repeated. Again, you can see how small that footprint is there, and you can imagine with a larger anchor, that footprint might be difficult to place two threaded anchors. So I'll take the number 5 suture from the anterior anchor, as you can see here, and then posteriorly we'll retrieve a shuttling suture. I like to push the sutures out of the way and pull back on the suture with the loop. I'll have my assistant do that so it delivers a loop to me and I know exactly which suture to retrieve. Then outside the cannula, I'll pass that #5 through the loop, and then I can simply pull on the other end of the loop suture to deliver the #5 suture into the sheath. In this case, the suture from the anterior anchor is delivered into into the sheath of the posterior anchor. Then I'm going to retrieve the posterior suture, retrieve the one that's slack because I know I haven't pulled on that one, and I need to pass that one into the anterior anchor. I've retrieved the loop. I'll shuttle that into place, and there I have my double mattress suture. This gets a nice bridge between the anterior medial anchor. As we can see on the intra-articular view, really nicely poses the rotator cuff to the footprint, and then we simply take those sutures out to a lateral anchor as we showed before, and there's our knotless double row repair.