Bio Mini-Revo - University Of Washington

BioMini-RevoSurgical Technique MINI SIZED, MAXIMUM PERFORMANCESelf-Reinforced 96L/4D Poly Lactic AcidLow Profile Instrument SetHigh Pull-out StrengthProven Screw-in Design Ensures OptimalPurchase in bone

#2 Hi-Fi High Strength SutureBio Mini-Revo 3.1mm Outer DiameterSelf-Reinforced96L/4D PolyLactic AcidPreloadedDisposableInserterProximal and distallaser etch marks2.1 mm Bone Punch2.1 mm Drill Bit2.4 mm TapSerrated Drill GuideFishmouth Drill Guide

Bio Mini-Revo Mini Size, Maximum PerformanceSurgical TechniqueINTRODUCTIONThe Bio Mini-Revo suture anchor is a 3.1mm diameter screwin implant manufactured from ConMed Linvatec’s patented SelfReinforced 96L/4D Poly Lactic Acid. The implant is pre-loadedon a disposable driver and is pre-threaded with #2 Hi-Fi highstrength suture. The combination of high pullout strength and idealbioabsorbable characteristics in a small pre-loaded implant willmake it the implant of choice for all shoulder instability procedures.The unique low profile instrument set that includes drill guides, drillbit, bone punch and a self-drilling tap provide precise placementof the pilot hole and the implant for a reproducible technique.The following techniques are describedby Stephen J. Snyder, MD, Van Nuys, CA

Bio Mini-Revo Surgical TechniqueAnterior Instability Reconstruction and Posterior Capsular PlicationThis arthroscopic shoulder instability procedure can be performed with the patient either in the lateral decubitusor beach chair position. For the lateral position, the arm is suspended in 70 degrees of abduction and 10 degreesof forward flexion using a shoulder traction device. The standard posterior mid-glenoid portal and a high anteriorsuperior (rotator interval) portal are established using an outside-in technique. A mid-glenoid operating portal iscreated by first inserting a spinal needle 2 cm inferior and 1 cm medial to the anterior superior portal so that itenters the joint at the superior-lateral attachment of the subscapularis tendon. A 8mm Dry-Doc operatingcannula is inserted either directly into the joint or over the guide rod (when the portal is already established).The scope is maintained in the anterior superior portal for viewing both the anterior and posterior repair.Posterior Plication StitchesStep 1 –To begin the posterior-inferior capsularplication a synovial rasp is used to abradethe posterior inferior capsule and the labraledge. A ConMed Linvatec 4.2mm UltraCut blade is also used to debride any frayed ortorn labral or synovial tissue.1Step 2 –Insert a 8 mm Dry-Doc cannula into the posterior portal.Create the first posterior plication stitch by inserting a45 or 60 degree Spectrum II Suture Hook loaded witha Shuttle Relay suture passer into the posterior midglenoid portal. The first stitch is made at the 6:30 position about 1 to 1.5 cm away from the labrum. Pass theneedle perpendicularly through the capsule and rotateit to capture a 4-5 mm “pinch” of tissue. Advance theneedle to the labrum-capsule junction to pierce thetissue so that the needle exits near the articular cartilage.Retrieve the Shuttle Relay out the anterior mid-glenoidportal with an arthroscopic grasping forceps.2

Designed in conjunction with Stephen J. Snyder, MDStep 3 –Load the Shuttle Relay suture passer witha #2 polyester suture and pull back throughthe labrum and out the posterior Dry-Doc cannula.3Step 4 –Using a crochet hook from the anteriorportal, retrieve the posterior limb of thesame suture out the anterior cannulaand the anterior limb into the posteriorcannula to prepare for a figure-8 stitch.4Step 5 –Pass the Spectrum II Suture Hook loaded witha Shuttle Relay again through the capsule andlabrum in a second “pinch-tuck” about 1 cmposterior and parallel to the first pass.5

Bio Mini-Revo Surgical TechniqueStep 6 –Load the Shuttle Relay suture passer withthe suture in the anterior mid-glenoid portaland carry it back through the labrum andinto the posterior cannula.6Step 7 –Using a crochet hook, the other limbof suture is retrieved out the posteriorcannula.7Step 8 –Store this pair of sutures in a green SutureSaver sheath outside the posterior cannula.They will be tied after the anteriorstabilization is completed.8

Designed in conjunction with Stephen J. Snyder, MDStep 9 –Perform additional posterior plicationstitches as needed, either as simple,horizontal mattress or Figure-8 stitchesand store each pair in a Suture Saver sheath outside the posterior cannula.9Step 10 –Loosen the Suture Saver sheaths and backthem out a few centimeters to relax the posteriorplication sutures so that capsule is not tight whileperforming the anterior reconstruction.10Step 11 –Mobilize the anterior–inferior capsuleand labrum by detaching them from theneck of the glenoid using a Liberator knife/elevator . The bone surface islightly debrided using a ConMedLinvatec UltraCut shaver blade11

Bio Mini-Revo Surgical TechniqueAnterior Instability ReconstructionStep 12 –The Bio-Instability Fishmouth Drill Guideis inserted through the anterior mid-glenoidDry-Doc cannula to the desired location 1-2mm on the articular surface around the 5:30position.12Step 13 –The 2.1mm Bio-Instability Drill Bit ispassed through the guide and drilledinto the bone until the distal depth markis below the bone surface and the proximal depth stop has made contact withthe Drill Guide.13The 2.4mm Bio-Instability Bone Punchmay also be used for this this step.Step 14 –The 2.4mm self-drilling Bone Tap isinserted through the drill guide andscrewed into the pilot hole until thehorizontal distal etch mark is belowthe bone surface.14

Designed in conjunction with Stephen J. Snyder, MDStep 15 –The Bio Mini-Revo implant is inserted throughthe drill guide and into the pilot hole until thedistal depth mark on the driver is below thebone surface. Do not advance the driver pastthis point or implant breakage may occur.A two-finger torque insertion technique is recommended. Align the vertical etch marks towardthe anterior inferior capsule to ensure that theeyelet is directed toward those tissues. Removethe driver by pulling straight back, being surenot to toggle it or change the alignment.15Step 16 –Use the crochet hook through the posteriorcannula, to retrieve the suture limb from theanchor that is on the anterior inferior side ofthe anchor.16Step 17 – A 45 or 60 degree Spectrum II Suture Hookloaded with a Shuttle Relay suture passer ispassed through the capsule and “under” thelabrum to form a “pinch-tuck” stitch. The ShuttleRelay is retrieved out the posterior cannula staying above the anchor with a grasping forceps.17

Bio Mini-Revo Surgical TechniqueStep 18 –The Shuttle Relay suture passer is loadedwith the suture outside the posterior cannulaand carried across the glenoid, the labrum and out the anterior mid-glenoid Dry-Doccannula.18Step 19 –Test the mobility of the sutures to besure they easily slide through the eyelet.If they slide easily, an SMC or other sliding knot is used. If they do not slide, astatic knot such as the Revo knot shouldbe used.19Step 20 –Additional Bio Mini-Revo implantsare inserted moving inferior to superioruntil the labrum is securely fixed tothe glenoid.20

Designed in conjunction with Stephen J. Snyder, MDTying the Posterior Plication SuturesStep 21 –Remove the posterior cannula from the posteriorportal and retighten the posterior Suture Saver sheaths down to the capsule and clamp them.Release the clamp from the most superior SutureSaver sheath and pull the sutures and the sheathinto the cannula using an arthrosocpic grasper.21Step 22 –Push the Suture Saver sheath back downto the capsule and hold it straight so that itcan function as a guide rod. Push the cannulaback into the joint over the sheath, remove thesheath and tie the sutures using a Revo knot.22Step 23 –Tie the remaining sutures using a similartechnique to finish the operation.23

Bio Mini-Revo This product contains Dyneema Purity.Dyneema Purity is a Registered Trademarkof Royal DSM N.V.Surgical TechniqueImplant Description.Cat. No.Bio Mini-Revo, Pre-threaded with one strand of . . C6170H#2 Hi-Fi, disposable driverBio Instability Instrument SetBio Instability Drill Guide, Fish Mouth. C6171Bio Instability Drill Guide, Serrated. C6172Blunt Obturator. C6173Sharp Trocar. C6174Bio Instability Drill Bit, 2.1mm. C6175Bio Instability Bone Punch, 2.1mm. C6176Bio Instability Self-Drilling Bone Tap, 2.4mm. C6177Bio Instability Sterilization Tray. C6178Suture Passing InstrumentationSpectrum II Handle. C6350Spectrum II Sterilization Tray. C6355Spectrum II Roller Wheel Replacement Kit. C6356Suture Hook, 45 Right, Limited Reuse. C6360Suture Hook, 45 Left, Limited Reuse. C6361Suture Hook, 60 Right, Limited Reuse. C6362Suture Hook, 60 Left, Limited Reuse. C6363Suture Hook, 90 Right, Limited Reuse. C6364Suture Hook, 90 Left, Limited Reuse. C6365Suture Hook, CorkScrew, Right, Limited Reuse. C6366Suture Hook, CorkScrew, Left, Limited Reuse. C6367Suture Hook, Straight, Limited Reuse. C6368Suture Hook, Crescent, Small, Limited Reuse. C6369Suture Hook, Crescent, Medium, Limited Reuse. C6370Suture Hook, Crescent, Large, Limited Reuse. C6371Suture Hook, 45 Right, Sterile, Disposable (Red). C6380Suture Hook, 45 Left, Sterile, Disposable (Blue). C6381Suture Hook, 60 Right, Sterile, Disposable (Orange). C6382Suture Hook, 60 Left, Sterile, Disposable (Yellow). C6383Suture Hook, Straight, Sterile, Disposable (Pink). C6384Suture Hook, Crescent, Small, Sterile, Disposable (White). C6385Suture Hook, Crescent, Medium, Sterile, Disposable (Teal). C6386Suture Hook, Crescent, Large, Sterile, Disposable (Purple). C6387AccessoriesLoop Handle Knot Pusher. C6112Crochet Hook. C6105Suture Scissor, 3.4mm Diameter, Straight.GU1005Guillotine Suture Cutter, 3.5mm Diameter, Straight . GU1007Grasping Forceps, 3.4mm Diameter, Straight with Ratchet . . 11.1001Suture Retrieval Forceps, 3.4mm Diameter.16.1018Liberator Knife.25.50014Suture Saver Kit (5 kits/box). C6180*Rasp Liberator Knife. 25.50017Rasp, 30 degree, top and bottom serrations. C8537.1Mini-Probe, 3.5mm dia., straight. 21.1001Shuttle Relay Suture Passer (10/box). C6004Dry-Doc Cannula, 8.0mm x 75mm, yellow (5/box). C7367Reusable, Cannulated Obturator, 8.0mm x 75mm. 9833Dry-Doc Cannula, 8.0mm x 85mm, red (5/box. C7368Reusable, Cannulated Obturator, 8.0mm x 85mm. 9834*Build to order, not CE Marked 2006 Linvatec Corporation, a subsidiary of ConMed Corporation, 2/2006, CST 3029

Bio Mini-Revo Mini Size, Maximum Performance Surgical Technique inTrODucTiOn The Bio Mini-Revo suture anchor