Arthroscopic Shoulder Repair Using the Smith & Nephew KINSA ...

Reviewed by:Larry D. Field, MDMississippi Sports Medicine and Orthopaedic CenterJackson, MSGary M. Gartsman, MDClinical ProfessorDepartment of Orthopaedic SurgeryThe University of Texas Health Science Center at HoustonTexas Orthopedic HospitalHouston, TexasPhilippe Landreau, MDShoulder and Knee SurgeonMedical and Surgical Center of Paris 5Department of Orthopaedic SurgeryLa Pitié-Salpétrière HospitalParis, FranceLars Neumann, FRCS (Ed)Consultant Shoulder and Elbow SurgeonThe Nottingham Shoulder and Elbow UnitNottingham, United Kingdom

Arthroscopic Shoulder Repair Using theSmith & Nephew KINSA Suture AnchorIntroductionThe Smith & Nephew KINSA Suture Anchor forinstability (Figure 1) is intended to provide securefixation of soft tissue to bone. The KINSA Anchorconsists of a tap-in, non-absorbable polymeranchor, preloaded with ULTRABRAID Suture(cobraid) and loaded onto a disposable inserter. Aself-locking, sliding knot, based on the Smith &Nephew FAST-FIX Meniscal Repair System, iscontained in the anchor allowing secure fixationwithout tying any knots. The design allows thetension placed on the tissue for fixation to be totallyindependent of the anchor depth. A suture loopreduces the tissue, leaving a low profile repair withno knot stack in the joint.Patient PreparationPlace the patient in either the beach chair positionor the lateral decubitus position.Typically, the posterior portal is used forarthroscopic visualization. Establish a standardposterior portal at the “soft spot.”Establish the anterior-superior portal (referred to inthis technique as the “non-operative” cannula) inthe rotator cuff interval.Establish the anterior-inferior portal (referred to inthis technique as the “operative” cannula) as closeas possible to the superior edge of thesubscapularis tendon.AnchorEtch mark (hidden)Outer inserter shaftInner inserter shaftHandleULTRABRAID Suturecobraid loopSuture leaderImpaction knobFigure 13

Figure 2Technique1. In preparation for the procedure, remove themonofilament from the Smith & NephewACCU-PASS Suture Shuttle. Reload themonofilament so that when advanced the tailends pass through the needle first (Figure 2) oruse a preferred method of suture shuttlepassage.2. Place the distal tip of a Smith & Nephew InlineDrill Guide onto the bone at the desiredimplantation site.3. Stabilize the guide over the insertion site andadvance the Smith & Nephew KINSA Drill Bituntil the shoulder on the drill bit reaches thebone surface, or the wide etch mark on the drillbit fills the distal windows of the inline drill guide(Figure 3). Note the drill bit alignment and holelocation before removing the drill bit and drillguide. The anchor will need to be inserted onthe same alignment and angle.4. Remove the drill bit and drill guide from theinsertion site. Mark the edge of the hole usinga preferred method. It is strongly recommendedto mark the edge of the hole (Figure 4) becauseit can be difficult to find later.Figure 34Figure 4

5. Insert the suture shuttle down the operativecannula and through the labrum and capsule tobe repaired (Figure 5). Advance the tails into thejoint space. Use a grasper to retrieve the tailsthrough the non-operative cannula (Figure 6).Hemostat the monofilament tail ends to preventslippage. Remove the suture shuttle whilebacking off the monofilament, leaving themonofilament loop exiting the operative cannula.Figure 5Figure 65

Figure 76. Pass six inches of both limbs of the coloredsuture leader, preloaded on the KINSA SutureAnchor, through the monofilament loop end(Figure 7). Shuttle the colored suture leaderthrough the tissue by pulling the tails of themonofilament out the non-operative cannula(Figure 8). Remove the monofilament.7. Advance the inserter down the operativecannula while pulling on the colored sutureleader to remove slack (Figure 9). Advance untilthe loop of ULTRABRAID Suture has passedthrough the soft tissue and is visible on bothsides of the tissue (Figure 10).Note: As you advance the inserter, position it sothe slot on the outer shaft faces toward thelabrum and away from the glenoid. Avoidtwisting the suture.Figure 86Figure 9

8. Pass the anchor completely through the loop ofULTRABRAID Suture which has been passedthrough the soft tissue (Figure 11). Use thecolored suture leader to help manipulate theloop.9. Insert the anchor tip into the drill hole andestablish alignment (Figure 12). Maintain axialalignment of the anchor relative to the drilledinsertion site. Tap the anchor slowly into thehole until the laser mark on the inner insertershaft is fully buried beneath the articularsurface. Because the laser etch mark is 3 mmabove the anchor head, the anchor will becompletely embedded in the subchondral bone.Note: Axial alignment of the anchor to thedrilled hole during implantation is imperativefor successful implantation.Figure 10Figure 11Figure 127

Figure 1310.Press the inserter against the anchor and pullback the outer inserter shaft, as it is no longerneeded (Figure 13).11. Continue to maintain pressure on the anchorwith the inserter and pull back slowly on theimpaction knob to shorten the loop that ispassed around the tissue (Figure 14). Continueto pull on the impaction knob until the loopreduces tightly around the inner shaft of theinserter. Pull the colored suture leader to helpremove any slack from the ULTRABRAID Suturecobraid loop.12.Pull back on the inserter to disengage it from theanchor (Figure 15).13.Continue to pull the impaction knob, advancingthe tissue to the repair site, until the desiredamount of tissue tension is achieved.Note: It is important to pause during loopreduction and pull on the colored suture leaderto remove any slack from the suture loop.Figure 148Figure 15

14.Release the ULTRABRAID Suture by first pullingthe suture clockwise. This will “walk” thesuture around the knob, following the arrow(Figure 16a), until it slips out of the straight slot(Figure 16b). With the suture clear of the straightslot, reverse direction (Figure 16c), turningcounterclockwise, until the suture slips out of the“L”-shaped slot (Figure 16d). Remove and discardthe knob and inserter.15.Remove and discard the colored suture leader.Cut the ULTRABRAID Suture with theSmith & Nephew ELITE Sliding Suture Cutter.Probe the repair to check the quality of thefixation (Figure 17).acbdTechnical Tips and Pearls• To aid in verifying the alignment of the drilledhole, after removal of the drill guide and bit, aguide wire can be inserted to relocate the holeand check alignment. Remove the guide wirewhen verified.• Do not use excess force when advancing theKINSA Inserter down the cannula. Gently pullon the colored suture leader only enough tokeep tension on the suture and to avoid suturetangling.• During loop reduction, if one leg of suturetightens faster than the other it is best to stoppulling on the suture. Use a probe or hook toloosen the tight suture leg until its tension isequal to the loose suture leg. Continue with thereduction, repeating the loosening technique asnecessary. Uneven loop reduction is sometimesseen when a twist occurs in the suture, makingloop reduction difficult.• The fixation tension can be adjusted by pullingon the ULTRABRAID Suture anytime prior tocutting the suture. A probe can be used to verifythe fixation before or after the impaction knoband inserter are removed.• If bone quality is of concern, remove theimpaction knob and inserter early – during thetissue reduction step. Introduce and hold a knotpusher against the fixation site to support theanchor during suture loop reduction.• Do not remove the inserter prematurely, as itaids in suture sliding. Once disengaged, do notuse the inserter as a knot pusher.Figure 16Figure 179

Additional InstructionPrior to performing this technique,consult the Instructions for Useprovided with individualcomponents — includingindications, contraindications,warnings, cautions, andinstructions.Courtesy of Smith & Nephew, Inc.,Endoscopy DivisionCaution: U.S. Federal law restricts thisdevice to sale by or on the order of aphysician.Trademarks of Smith & Nephew. Certain marksregistered U.S. Patent & Trademark Office.EndoscopySmith & Nephew, Inc.Andover, MA 01810USAwww.smith-nephew.com+1 978 749 1000+1 978 749 1108 Fax+1 800 343 5717 U.S. Customer Service©2006 Smith & Nephew, Inc. All Rights Reserved.09/06 10600180 Rev. B