Notes on Sutures, Anchors, and Surgical Techniques

Sutures and Loops

  • Tygo Loops:

    • Generally good.

    • Two sizes used: 2mm and 1.25mm.

    • The 2mm loops have a cutting needle.

    • The 1.5 taper loop has a smaller needle with a taper.

Needle Preferences

  • Needle Size:

    • MO6 is a common needle size.

    • For 2mm loops, the needle might be too small.

    • Using smaller needles for FDL is acceptable, but for smaller tendons, there is a risk of tearing.

  • Needle Type:

    • Straight needles are preferred for loops.

    • Straight needle length was considered good.

Anchor Feedback

  • 4.75 Dual Infinity Anchor:

    • Thumbs up.

  • Brosstrom Knotless Screw-in Dual Infinity (4.75):

    • Thumbs up.

    • Suitable for both the tibia and talus, and potentially for the figure.

  • Manticore for Brosstrom:

    • Not necessary, though it could work for smaller sizes or the talus.

    • Suitable for internal brace constructs in the talus, especially for non-novice users sliding the MantaPort.

Manticore Considerations

  • 2.9x8mm Manticore:

    • Not suitable for use with 2mm tape because it would cover the threads too much.

    • Typically used with a number two or 1.5 suture.

Anchor Issues

  • Labral Anchor:

    • May have pulled out because it was used with too big a tape (2mm).

    • Dr. Lam uses smaller sutures for his Brosstroms with this anchor.

Suture Performance

  • All Sutures:

    • Single-loaded 1.6mm sutures were good.

    • Double-loaded sutures were good, but require proper instrumentation.

    • Single-loaded 1.6mm not used in this session, but acknowledged (not yet released).

    • Instrumentation for the single-loaded anchor isn't yet finalized.

  • Nautilus:

    • Used in the big toe; worked great.

  • 2.3 Double Loaded Sutures:

    • Worked well.

Drilling Depth

  • Drill Depth for Brochures:

    • Current drill depth is 23mm, but the goal is to reduce it to no more than 16mm.

    • References 1619 drilling the Theranos.

Knotless All-Suture

  • Easy to tension, unlike some other systems, such as Element where tensioning requires significant effort.

    • Other tensioning system you sometimes have to fight to achieve the desired tension, feeling like it might not work.

Deltoid Procedures

  • Knotless All-Suture:

    • Used for the deltoid; results were positive.

    • 2.3 double-loaded sutures were preferred.

  • 4.75 or 5.75 Dual Infinities:

    • Likely to work for the deltoid, but there's a risk of overtensioning, especially with the Manticore.

    • It's difficult to back off the tension with the Manticore.

    • Manticore is too bottom loaded.

FDL Transfer

  • Performed twice using two different methods:

    • Boomerang button: Worked well.

    • TygoLoop plus Manticore: Worked great, providing solid fixation even with poor bone quality.

Bunion Correction

  • Soft Tissue Bunion Correction (Capsulorphy):

    • Performed with knotless all-suture; received very positive feedback.

    • Used either a 1.6 or 2 single-loaded round suture.

FHL Tracker

  • Performed with a boomerang button.

Anchor Selection

  • Swivelock vs. Manticore:

    • Manticore's post-tensioning ability is appealing.

    • For FDL, a boomerang button is typically preferred, unless there's poor bone quality, in which case the Manticore would be beneficial.

    • Swivolux is preferred for Brosstrom to avoid overtensioning.

    • A 3.5-3.75 knotless Manticore style is generally used.

Suture Options

  • A 2.3mm knotless all-suture option could facilitate a four-corner suture technique for Haglund's, offering a non-PEEK alternative.

  • Currently, knotless sutures used for Brostrom are single-loaded Nautilus.

  • A double-loaded option may be beneficial for Haglund's repairs to create a box-like construct with suture strands.

All Suture Considerations

  • Triple-loaded all-suture: Unnecessary due to too much material.

  • For double-loaded sutures in Haglund's, swedging all four strands into one for a single pass may be worthwhile; similarly, swedge two legs for single-loaded options.

    • Unswedged options should also be available for procedures like Brostrom where sutures are repaired in a sheet.

Additional Points

  • Two O's in goose.

  • Consider plaque placement for alternates, close to the skin.

Instrumentation Feedback

  • Instrumentation is generally well-received: easy to use and feels high quality.

  • Reusable instruments are cost-effective, especially in ASCs, where they can significantly reduce implant costs.

Cost Comparison

  • Implants cost around 400-500, which is at least 20% lower than Arthrex. Arthrex cases, including everything else, may cost around 2500. Cutting costs and maintaining quality are important.

Material Quality

  • The tactile feel of the materials is crucial; flimsy materials can give a negative impression.

  • The instruments have a solid, impressive feel compared to lighter plastic alternatives.

  • Robustness testing is important for FDA approval (ISO scanner).

Manticore Improvements

  • A depth guide for drilling and implantation would be beneficial due to minimally invasive procedures and tissue obstruction.

  • Incorporate a positive stop or line for alignment and suture cleat.

Simplifying Procedures

  • Simplifying procedures is crucial for user-friendliness, especially to ensure success on the first attempt.

  • Many surgeons, particularly older ones, may only give a product one chance.

Cost and Revenue

  • Offering a 20% cost reduction can attract surgeons, especially those with investments in surgery centers.

  • Some surgeons have a fiduciary responsibility to maximize income at their surgery centers.

Instrument Trays

  • Incorporating instruments into existing trays and offering loaner sets can be appealing.

  • Combining foot, ankle, and shoulder trays may attract some ASCs.

Waste Reduction

  • Reducing waste and unnecessary packaging is significant.

  • Being able to replace individual components rather than entire kits can save costs, especially in cases of dropped or damaged instruments.

Dual Infinity Handle

  • The current length of the dual infinity handle is acceptable, potentially shorter is preferable.

Button Design

  • The new button design is superior due to its secure feel during insertion and reliable deployment.

  • There will be two in a set.

Suture Needs

  • Anchor with two sutures with four needles?

  • There may be some surgeons saying that it's crucial for Haglund's repairs but for others it may be unnecessary; two needles per limb are sufficient.

  • If surgeon need that they can always cut it.

Suture Guard Clip

  • The suture guard clip is acceptable but should be cut in half hamburger style to reduce its width.

  • Alternative options include a rubber protector or a rubber tip protector on the needles.

Instrument Packaging

  • Some surgeons may find a needle to be too long.

  • Folding or moving the foam piece packaging to something safer.

Loop and Suture Technology

  • It's imp. To have something on the loop to have the needle slide, but it's patented by something else.

Trademark Notes

  • Lapoplasty: Trademarked name.

  • SpeedWhip: Arthrex has trademarked the term.

  • Green Repair: Consider trademarking this term associated with Tyga.