KNEE

HIP

SHOULDER

EXTREMITIES

SHOULDER TECHNIQUE GUIDE

Roy Majors, MD

Arthroscopic Shoulder Instability Repair Using the Curved Guide and Anchor Delivery System

Arthroscopic capsulorrhaphy, labral repairs, and SLAP repairs are some of the most demanding procedures facing the surgeon. Anchor placement is possibly the most important part of the procedure. Improper anchor placement can lead to anchor pull-out, joint damage, or non-anatomic tissue repair. Currently available straight anchor guides can make it difficult for the surgeon to accurately place anchors.

Smith & Nephew has developed a curved guide and anchor delivery system that gives the surgeon the tools necessary to consistently place anchors with an optimized trajectory in various positions on the glenoid rim1. This system allows for the delivery of Smith & Nephew’s current BIORAPTOR™ 2.3 PK or OSTEORAPTOR™ 2.3 PLLA/HA Suture Anchors which have been successfully used in thousands of cases.

As described by:Roy Majors, MD OrthoCarolina, Charlotte, North Carolina

Arthroscopic Shoulder Instability Repair Using the Curved Guide and Anchor Delivery System

3SHOULDER TECHNIQUE GUIDE 10600876 Rev. A

INSTRUMENTATION

The curved guides are reusable, stainless steel, cannulated, curved shafts with ergonomic handles designed to aid in alignment and improved anchor placement during drilling and anchor insertion. Insertion of the curved guides is aided by the flexible obturator – a reusable, stainless steel, pliable shaft with a blunt tip and handle – which has been designed to occlude soft tissue during insertion.

The flexible drill used with the curved guides is made of stainless steel and includes a fluted bit designed to optimally create the required pilot hole.

These instruments are designed for use only with the Smith & Nephew BIORAPTOR™ Curved 2.3 PK and OSTEORAPTOR™ Curved 2.3 PLLA/HA Suture Anchors, preloaded on flexible inserters with high-strength ULTRABRAID™ Suture.

PATIENT PREPARATION AND PORTAL PLACEMENT

The surgeon can easily use the curved guide and anchor delivery system in both the beach chair and lateral decubitus positions.

1. Drape the shoulder so that the surgeon has unrestricted access to the shoulder.

2. Establish a standard posterior portal at the “soft spot.” Typically, the posterior portal is used for arthroscopic visualization.

3. Establish the anterior-superior portal (for the “non-operative” cannula) in the rotator cuff interval.

4. Establish the anterior-inferior portal (for the operative cannula) as close to the superior edge of the subscapularis tendon as possible.

fishmouth tip

crown tip

4 SHOULDER TECHNIQUE GUIDE 10600876 Rev. A

PREPARATION OF THE TISSUE

Prepare tissue in the manner to which the surgeon is accustomed. Ensure the capsulolabral structures are well-mobilized to allow for an anatomic repair or adequate advancement of tissue, if needed. Debride all soft tissue from the glenoid neck at the rim level and below using the Smith & Nephew INCISOR™ Blade, 4.5 mm, concave, curved. If needed, use the Smith & Nephew 4.5 mm Shielded Burr to roughen the bone to promote tissue healing.

STEP 3STEP 1

STEP 2

INTRODUCTION AND POSITIONING OF THE GUIDE ON THE GLENOID

Place the curved guide through the anterior-inferior 8.0 mm x 72 mm CLEAR-TRAC™ Flexible Cannula for anchor placement (operative cannula).

Ensure that the curved guide moves freely in the cannula. Turn the guide so that its curve matches the curve of the humeral head. Move the curved guide tip to the desired position on the glenoid rim. Place the tip of the curved guide (convex side) on the glenoid face side of the rim. Rotate the curved guide onto the face of the glenoid to the desired position by turning the handle of the curved guide. Maintain gentle forward pressure on the curved guide to prevent it from slipping off the glenoid. Once the tip of the curved guide is on the glenoid face, rotate the tip to create a perpendicular angle to the glenoid face.

DRILLING THE HOLE

Maintain firm pressure on the curved guide in both a forward and rotational direction. Place the flexible drill bit into the curved guide. Begin running the drill as the drill bit passes down the curved guide to decrease any resistance of the drill bit passing around the bend of the guide. When the drill tip engages bone, the auger design pulls the tip forward until it is fully seated. While removing the drill bit, continue to run the drill in forward mode to decrease resistance of the drill bit against the guide bend as it exits. It is best to perform insertion/drilling/extraction in a single motion, maintaining firm pressure on the curved guide in both a forward and rotational direction with the drill constantly running in forward mode.

Note: Guide alignment change while drilling may cause drill bit breakage. Maintaining guide alignment throughout drilling is required to ensure drill bit integrity.

INSERTING THE ANCHOR

Align and place the inserter into the curved guide, maintaining pressure in both a forward and rotational direction. Ensure that the ‘V’ on the anchor inserter handle aligns with the laser marks on the guide before tapping the anchor into the bone.

Begin to gently tap the anchor handle to decrease any resistance of the anchor as it passes down the curved guide. Once the anchor engages in bone, continue to tap the handle of the inserter until it is completely seated on the top of the curved guide.

STEP 4

5SHOULDER TECHNIQUE GUIDE 10600876 Rev. A

STEP 5

STEP 6

RELEASING THE ANCHOR

Once the anchor is completely inserted, release the sutures from the handle by pulling back the lime green, spring-loaded collar. Draw the handle back from the top of the curved guide.

Tip: A gentle, back-and-forth twisting motion can be helpful in removing the anchor inserter from the curved guide.

PASSING THE SUTURE THROUGH THE LABRUM

Insert the ACCU-PASS™ Suture Shuttle down the operative cannula and through the labrum and capsule to be reattached/shifted.

Advance the monofilament loop into the joint space by rolling both of the side wheels of the suture shuttle in a downward motion (do not remove the suture shuttle at this point).

Using an ELITE PREMIUM Suture Loop Vertical Grasper down the non-operative cannula, reach through the monofilament loop, grasp a limb of ULTRABRAID™ Suture and pull it through the loop and out of the non-operative cannula.

Remove the suture shuttle from the operative cannula with the suture limb passed through the loop.

Both limbs of suture are now in the operative cannula.

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STEP 7

STEP 8

STEP 9

TIE THE KNOTS

Using desired knot-tying technique, tie the limbs of ULTRABRAID™ Suture.

CUT THE SUTURE LIMBS

Using the Smith & Nephew suture cutter, cut the suture limbs to the desired length.

FINAL REPAIR

Repeat steps 1–8, as necessary, in order to complete the repair.

7SHOULDER TECHNIQUE GUIDE 10600876 Rev. A

TECHNIQUE PEARLS

1. When drilling, ensure the drill guide is secure on the bone to avoid inadvertent slippage of the drill.

2. Use a CLEAR-TRAC™ COMPLETE Threaded Cannula with a minimum diameter of 8.5 mm or an 8.0 mm x 72 mm CLEAR-TRAC FLEXIBLE Threaded Cannula with the curved delivery system.

POSTOPERATIVE CARE*

Use an arm sling for two to four weeks. Begin protected range of motion keeping elbow in front of the plain of the chest. Avoid shoulder extension or excessive external rotation for the first six weeks. Lifting, pushing, and pulling should be limited during the first six weeks.

* The views and opinions expressed for postoperative care are solely those of the surgeon(s) and do not reflect the views of Smith & Nephew, Inc. In no event shall Smith & Nephew, Inc., be liable for any damages whatsoever (including, without limitation, damages for loss of business profits, business interruption, loss of business information, or other pecuniary loss) arising out of the use of or inability to use the expressed views.

References

1. Data on file at Smith & Nephew ITR-4616, 2011.

EndoscopySmith & Nephew, Inc.Andover, MA 01810USA

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. 07/2011 10600876 Rev. A

ORDERING INFORMATION

To order the instruments used in this technique guide, call +1 800 343 5717 in the U.S. or contact an authorized 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

Curved Suture Anchors and Guide Systems

72203280 BIORAPTOR™ Curved 2.3 PK Suture Anchor, w/one ULTRABRAID™ #2 suture (COBRAID-black)

72203281 BIORAPTOR Curved 2.3 PK Suture Anchor, w/one ULTRABRAID #2 suture (COBRAID-blue)

72203290* OSTEORAPTOR™ Curved 2.3 PLLA/HA Suture Anchor, w/one ULTRABRAID #2 suture (COBRAID-blue)

72203291* OSTEORAPTOR Curved 2.3 PLLA/HA Suture Anchor, w/one ULTRABRAID #2 suture (COBRAID-black)

72203156 Curved drill guide for 2.3 mm suture anchors, crown tip

72203298 Curved drill guide for 2.3 mm suture anchors, fishmouth tip

72203159 Flexible obturator for 2.3 mm curved guide and suture anchor delivery system

72203160 Flexible drill for 2.3 mm curved guide and suture anchor delivery system

* CE mark pending

ACCU-PASS™ Suture Shuttles

7210423 45º, left, sterile

7210424 45º, right, sterile

7210425 45º, upbend, sterile

7210426 Straight, sterile

7210427 Crescent, sterile

72200419 70º, upbend, sterile

Disposable Burrs, Disposable Blades, Disposable Cannula, and Reusable Obturators

7209335 4.5 mm shielded burr, box of 6, sterile

7205332 INCISOR™ Blade, 4.5 mm, concave, curved, box of 6, sterile

72200902 CLEAR-TRAC™ COMPLETE Threaded Cannula, 8.5 mm x 90 mm, with disposable obturator, 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)

Reference # Description

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

CAUTION: U.S. Federal law restricts these devices to sale by or on the order of a physician.