Eric I. Ferkel, MD (Los Angeles, CA), demonstrates the Chondral Dart™ multishot technique for chondral fixation.

Orthobiologics

Knee

Human

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English  - en

video

Osteochondral Flap Repair System With Chondral Dart™ Implant

Today we'll be discussing control darts and its utilization in control flap fixation. On our table, we see a single shot cannula with its sheath, which the cannula allows for easier utilization of this system in the arthroscopic setting. To the right, we see a inserter followed by a single shot drill. In the middle, we have our two and four hole guide sleeves, followed by the drill pins, and then we see our two blunt pins, which allow to hold the guide sleeve in position. As you remove the drills and allow for insertion of your darts. Finally, we see our control dart inside its implant case, so we've removed the dart for better visualization. Here we see the dart, which is a bioabsorbable PLA double reversed barbed to facilitate fixation and compression of the chondral flap. The control dart comes in an 18 millimeter length and is 1.3mm in diameter. It allows for secure fixation under the highland cartilage surface to eliminate contact with the articulating joint surface. So let's move over to the knee right now and show what the lesion looks like and how we can utilize the condo dart in the knee. Arthroscopically we're panning over to the lateral femoral condyle where we see a lateral femoral condyle, full thickness chondral defect over here. And as we kind of lift it up, we see the full thickness nature of that defect with barely any bony attachment back there. And we want to really be careful here to allow that hinge to remain intact, not to displace that chondral defect as you want to sit it right back into its home for fixation later on. So right now we are showing the zebra probe, which allows for improved measurement of a defect. You can move this knob back and forth to allow to improve your measurement intra articularly. So now we're bringing our zebra probe into the knee here to allow us to get a better measurement of the width and length of the Chondral defect. As we bring the probe across here, we can see here that the length is approximately ten millimeters. And then as we open up the jaws of the probe here, we can get a measurement right there of approximately 9 to 10mm. Chondral darts can be utilized in condl defects up to 20mm. So here we have the two hole drill guide to allow for fixation of the darts. Our plan here is to use three darts two at the edges and one centrally. It is important to have the edges to sit flush to prevent any catching during movement of the knee from flexion to extension. So first we're going to be placing the first drill into the two hole drill guide. There is a positive stop of this drill. And using the sheath and inserter to drill our next conical dart fixation hole. This allows for the dart to be placed immediately followed this drilling. So now we're going to bring the dart into view here with the rubber band still attached, attach it to the end of the inserter device, and then push the thumb pedal down to deliver the dart. Next will be the inserter, which will then place the dart fully into its position. Until the black inserter is flush with the sheath. All right, so now we're taking out the drill followed by placement of the inserter To hold the position of our two hole drill guide. And now we're going to place the control dart with the sheath. Now the second control dart is going to be placed by pushing your thumb paddle down. Followed by utilization of the inserter to plunge the dart into its position. Now we'll be placing a third dart to improve the compression of the control flap at the free edge. So it's critical to stay steady with the drill guide to prevent any sort of eccentric drilling as you go through, as well as eccentric placement of the dart. So now we're replacing the dart on the edge of the inserter and then pushing it through through the thumb pad, and then using the mallet to further deliver the dart into its position. I recommend a minimum of three candidates to secure the fragments that are greater than one centimetre in diameter. Additionally, for smaller lesions, a single shot kit can be used, or a multi-shot kit can be used with a two hole guide sleeve as shown today. Additionally, auto cart is a great option for certain lesions that cannot be fixed by taking down the control flap using a shaver and a graphnet, and re implanting the autologous chondrocytes over the defect site. At this point, one can consider utilizing the Apollo Small Joint 50 to achieve better contouring of the chondral flap edges. And so the final step in this case will be to bring the knee through full range of motion and confirm that there is no flap edges causing any sort of problems as you bring it through full articulation there.

Osteochondral Flap Repair System With Chondral Dart™ Implant

Asheesh Bedi, MD (Chicago, IL), discusses the evolution of inlay to onlay procedures and relates the progress to knee procedures using all-soft implants.
To learn more about inlay vs onlay literature and applications, read the <a href="https://www.arthrex.com/resources/DOC1-001585-en-US/inlay-vs-onlay-meniscal-repair-and-ligament-reconstruction?objectID=human.resource.en.e3224bf8-c6b3-4362-a73d-02891a13ba21.3&amp;queryID=ded5d0f4f84a213c82e3f2f0638d86d2" title="https://www.arthrex.com/resources/DOC1-001585-en-US/inlay-vs-onlay-meniscal-repair-and-ligament-reconstruction?objectID=human.resource.en.e3224bf8-c6b3-4362-a73d-02891a13ba21.3&amp;queryID=ded5d0f4f84a213c82e3f2f0638d86d2">scientific update.</a>

 Inlay vs Onlay for Knee Repair Surgery: What Does the Data Tell Us?

&nbsp;Inlay vs Onlay for Knee Repair Surgery: What Does the Data Tell Us?

Paul Brady, MD (Knoxville, TN), performs an upper-border subscapularis repair using the Double-Loaded Knotless 2.6 FiberTak soft anchor. This anchor features two repair sutures that are passed individually through the subscapularis, shuttled simultaneously within one knotless mechanism, and tensioned independently to achieve desired fixation.

Shoulder

Upper-Border Subscapularis Repair Using the Double-Loaded Knotless FiberTak® Soft Anchor

Hi, my name is Doctor Paul Brady. I'm from Knoxville, Tennessee, and today I'll be demonstrating an upper subscapularis repair utilizing A26 double loaded knotless FiberTak anchor. All right, so here we have a left shoulder. And you can see that rolled edge of the upper border of the subscapularis. If we do a little internal rotation and a little posterior lever push, you can see this upper subscapularis tear. This is a super common pathology that I see frequently. And I think it's missed frequently is because of failure to internally rotate, give it a little posterior push, and really see if those upper subscapularis fibers don't peel off the lesser tuberosity insertion. Okay, you can see where I've made my anterior portal here. I'm able to get a good angle of insertion into the upper portion of my lesser tuberosity. So we'll go ahead and use our drill guide inserter. But we'll go ahead and push that in. This is a self-punching anchor 2.6mm double loaded knotless FiberTak. And so then we'll remove the red tab. We'll pull our inserter off. And then I'll just give that a little tug to set that anchor. And you can see that's nice and set. So within this anchor we have two repair sutures. We have a black and white repair suture. Blue and white repair suture. And we have a striped shuttle suture. So we'll separate those from one another. And I'll start with my black repair suture. I'll load that into the the mouth of a Scorpion device. I think it's important. You can see my assistant's holding some gentle tension on those other sutures. So that as I insert this into the cannula, I'm not wrapping around those other sutures. So now we'll get a good bite of my upper subscapularis here. I'll get it right at the junction. I think that's a good bite there. We'll go ahead and pass that repair suture. So there's our first pass right there. You can see that repair suture. Pass through the tissue there nicely and we'll hold some tension on that. We'll grab our other repair suture the blue and white. Load that into the Scorpion. We'll take a little higher bite with the blue. So now we've passed both of our repair sutures through the subscapularis. A good purl is to take both of those repair sutures that you just passed and pull them out together. And that way, you know, there's no twist between your repair sutures and your shuttle suture. So now we'll go ahead and shuttle both of those through the anchor itself. I'll pass the repair sutures. So we're going to double over the suture right at this marked portion of the blue suture. You can see that purple mark on the blue suture. We're going to double it over and load it into the anchor itself. We're going to pull those repair sutures down into the anchor. You'll see them coming in here. Once we get in there, I usually give it a teeny little tug to pass it through before we completely tension this. I'm going to go through the two loops, and I'm going to use that shuttle suture as counter tension. And that way we're pulling both of them at about the same rate. And it reduces the risks of twisting as it's going down. So once we get there, I can pull it out. So once it gets tight, then we're going to alternate between my blue and my black suture to get my final tensioning here. All right. Last step. We'll load the repair sutures into our cutter. This mega loader is nice to facilitate that. And then we'll slide those right down on the bone. So let's go through that posterior lever. Push again just to make sure our repair is as secure as we think it is. It looks great with no tension on it whatsoever. Nice rolled edge of the subscapularis secured to the less tuberosity footprint. So we'll grab the elbow again. We'll give it a little internal rotation and a posterior lever. Push. And there you can really see a nice repair. Two points of fixation here. We've got our black suture there and our blue suture there into our 2.6mm self-punching double loaded knotless FiberTak anchor.

Upper-Border Subscapularis Repair Using the Double-Loaded Knotless FiberTak® Soft Anchor

This animation demonstrates unicondylar knee resurfacing using the iBalance® UKA system, which helps improve operative efficiency due to the expanded flexibility provided by the new adjustable spacer block.

Arthroplasty Knee

iBalance® UKA Technique

iBalance® UKA Technique

At the Advancements in Orthobiologics course, Alberto J. Panero, DO (Sacramento, CA), highlights the importance of addressing bony lesions and how the IntraOsseous BioPlasty® (IOBP®) technique plays a role in treatment.

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Treating Bone Marrow Lesions: IntraOssesous BioPlasty® (IOBP®) Technique

OrthoPedia: Treating Bone Marrow Lesions: IntraOssesous BioPlasty® (IOBP®) Technique

The Knotless FiberTak® biceps implant system offers a knotless, all-suture anchor solution to perform an onlay proximal biceps tenodesis at any location. The implant uniquely integrates two individual tensionable knotless mechanisms within a single FiberTak sheath. The blue FiberWire® repair suture passes around the biceps tendon, while the white suture loop is retrieved through the tendon. The blue repair suture is retrieved through the loop, and both are tensioned to complete the tenodesis.

Knotless FiberTak® Biceps Implant System for Proximal Biceps Tenodesis

In the subacromial space. Insert a cannula in line with the intended anchor insertion site. Place the drill guide on the bony surface of the proximal humerus at the desired tenodesis location. Drill a pilot hole using the 3.0mm. Drill until the positive stop on the drill guide is reached. Keep the drill guide in place and insert the Knotless FiberTak implant through the guide. Lightly tap on the inserter handle until it is flush with the drill guide. Remove the black suture release tab to remove the sutures from the inserter handle. Lightly pull evenly on the suture limbs to set the anchor in the bone. Using a suture retriever, shuttle the solid blue FiberWire. Repair suture under and around the biceps tendon to the opposite side of the white suture loop. Insert the loop and tack SwiftStitch. Suture passer and penetrate the biceps tendon at the desired tenodesis location. Retrieve and shuttle the shuttle the white tensioning suture loop through the tendon. Using a suture retriever. Retrieve the solid blue FiberWire. Repair suture through the white TensionLoc suture loop. Load the blue FiberWire. Repair suture through the shuttle link suture loop and fold the repair suture limb at the purple indicator mark. Pull the tape end of the shuttling suture to shuttle the repair suture through the knotless mechanism and tension the repair suture around the biceps tendon. Tension the white suture limb to lock the tendon to the blue circumferential stitch. Pull each suture limb sequentially to ensure adequate tension and a secure tendon reduction. Cut the suture. Limbs. Excise the biceps tendon 5 to 10mm proximal to the repair, and remove the remaining tendon stump from its attachment to complete the repair.

Knotless FiberTak® Biceps Implant System for Proximal Biceps Tenodesis

Erik Kubiak, MD (Las Vegas. NV), provides case examples of the application of KreuLock™ locking compression screws.

Foot and Ankle

Trauma Lower Extremities

KreuLock™ Locking Compression Screws in Trauma

Hello, my name is Eric Kubiak. I'm here from the University of Nevada, Las Vegas and the University Medical Center. Today we're going to talk about crew lock locking, compression screws and their use in fracture and trauma care. They feature a variable step thread pitch, are compatible with existing plates, and are available both in titanium and stainless steel. Kreulock locking compression screws are a unique implant for the treatment of periarticular injuries in trauma. They provide excellent compression across articular surfaces, which would otherwise need to be achieved by either the use of clamps or a lag screw fixation techniques. We'll go through a couple of use case scenarios and the use of the crew lock locking compression screw in the treatment of intra-articular injuries. This patient is a 42 year old male who sustained a distal impaction injury to the tibia, as demonstrated on these plain films, and made even more apparent on this surface rendered CT scan, which demonstrates the sort of explosion of the articular surface based upon the teachings of Rudy and Allgauer and all subsequent learning. Since then, we understand that these injuries have a guarded prognosis, but to achieve the best outcomes, we need to seal and compress the articular surface and restore the anatomic position of the distal articular fragments. To that end, we look at the lateral. It's very important that the talus remains centered under the reduced distal tibia. The KreuLock locking compression screws really help achieve this in providing further compression of the reduced articular surface, sealing that joint space, preventing the intrusion of articular fluid between the fracture fragments as they heal. And that reduction achieved by the active compression of the implant and the step thread pitch can be seen on these subsequent follow up radiographs with maintenance of the distal articular reduction. Now this is another example of a high energy distal tibia injury or the talus is impacted and exploded the distal tibia. In this case, this is a 42 year old male who was in a high speed MVC. Again, intrusion of the firewall classic for this injury with radiographs that demonstrate comminution of distal articular surface of the tibia and then service rendered CT scan, which really demonstrate all of the energy and part of the distal tibia and the frank explosion of the articular surface in response to the talus driving up into the distal tibia. Treat these injuries with external fixation, particularly in the high energy situation, to let the soft tissue calm down. Of note on this you can see the talus wants to almost sublux anteriorly, and the joint of the distal articular surface of the tibia seems expanded. Right pass through this sort of stitching the articular fragments back together. Compression of the fracture plane, placement of provisional fixation, and a clamp plate applied. Slide. And for me, still a suspicious position of the talus with respect to the anatomic axis of the tibia. Talus is displaced anteriorly. Articular surface is wide with respect to the talus left in this position. This fracture is probably going to do poorly. Application of the KreuLock compression screws. With further compression of the articular surface of the distal tibia and the AP plane, the talus is now centered under the anatomic axis of the tibia. Let's go back and look at that again. The talus is anterior. It's not really where the anatomic axis. We apply the KreuLock compression screws. And there's a restoration the talus underneath the tibia where it belongs in a congruent articular surface of the tibia which should provide long term support of the talus and give this patient the best chance for a great long term outcome. At two year follow up, you can see maintenance of the talus centered in the distal tibia. Maintenance of the articular. Reduction and maintenance of maintenance of that compressed distal articular surface was so critical to support the talus for the best potential long term outcome for this patient. Kreulock locking compression screw makes tremendous sense to classically trained orthopedic traumatologists. We've been taught for generations that when treating periarticular injuries, restoration of the periarticular anatomy and compression of the joint surface are critical to the long term outcome of that joint and the survivability of that joint for the patient. Kreulock locking compression screw. Achieves. All of those benefits of a lag screw fixation, with the additional benefit of being fixed angle locked to the plate, and not requiring additional steps to achieve that compression, particularly when the articular fracture is perpendicular to the trajectory of the screw. Thank you.

KreuLock™ Locking Compression Screws in Trauma

Travis Menge, MD (Grand Rapids, MI), demonstrates an arthroscopic hip labral repair and cam resection using the Synergy Vision™ system’s dual-view capability with the Pano™ Scope and NanoNeedle Scope 2.0.

Hip Labral Repair and Cam Resection Using Dual-View Imaging With the Synergy Vision™ System

I'm Doctor Travis Menge from Grand Rapids, Michigan. Today we're going to demonstrate an arthroscopic hip labor repair with camera section. And we're going to utilize the Synergy Vision system and highlight the capabilities to integrate the Nanoscope, the nano needle and the Fluoroscopic energy. This synergy Vision system allows you to take multiple sources and build them into one layout. The best part about this system is the ability to customize your images exactly how you'd like to see them. For example, you can see one image on your screen. You can change the layout to picture in picture and integrate two different images on your screen. You can even change it to picture in double picture, which allows you to see three images. And if you'd like to see a side by side of two images in a larger view, you can do that as well. And lastly, it allows you to bring all four images together on one screen to really help you throughout the surgical case. As we prepare to start our labor repair, you can see we are viewing through a traditional 70 degree scope looking at our drill guide. One thing that we cannot see is the articular cartilage. So we have to move our hand in order to see the articular surface. And while drilling, we want to be able to see that to ensure we don't penetrate the cartilage and cause iatrogenic damage. One unique feature about the nanoscope is when we turn it to Nanoscope mode. We can see both above the labrum as well as below the labrum with the articular cartilage in one view. And we now have the added advantage with the Synergy Vision system to bring up our secondary feed through a nano needle 2.0, which gives us excellent direct visualization of our anchor placement so we can transition our hand with the Nanoscope and get an even broader view of the articular cartilage. One thing that I really like is using the nano needle to visualize through the window while drilling, and that allows us to ensure that our drill guide is placed directly on the acetabulum in the optimal position. Now, as we begin to place our 1.8mm fiber tack anchor using the curved guide, we're going to visualize through the window on the guide to ensure that the drill stays on the acetabular rim, and this also allows visualization of the bone evacuation from the drill tunnel. As we place the anchor, we can utilize both the nano needle 2.0 as well as our scope to view the anchor, go into the drill site. This allows us to ensure proper placement as well as trajectory of the anchor. Now that we have our anchor in the bone, I'm going to separate the blue repair stitch from the white passing sutures. I then run the white sutures to ensure all the bone debris is not entrapped within the anchor site, and also set the anchor with a gentle pull. You can see the anchor is set securely in the bone, both from the nano needle 2.0, as well as our scope view. Now that we have our anchor placed, we're going to use the Swift stitch suture passer in order to pass the repair stitch around the labrum. Now that we've passed the repair suture, I like to run the two passing sutures in order to ensure that they run smoothly. We then place the repair suture through the looped end of the passing suture, and this allows us to shuttle the repair stitch through our knotless mechanism. Now that we've placed our first anchor, we will place two more anchors to complete our labor repair and then move on to the camera section. One benefit of the Synergy Vision system is we can see both above and below the labrum, as mentioned before, which allows us to ensure we protect the articular cartilage when passing our suture, both from the nano needle 2.0 as well as our scope view. Now that we've completed our labral repair, you can see the Cam lesion that we've exposed and we are now ready to begin with our camera section utilizing the scope. We have a beautiful over the top view of our planned resection area. We can see the extra bone and how we're going to work from an anterior to posterior direction in carefully resecting that Cam lesion to restore the femoral head neck offset. Now that we've demarcated our proximal extent of our camera section, I'm going to show you guys something really cool. We're going to be able to bring in a secondary view through the synergy vision and through our nano needle. We can now see the offset in our planned resection for restoring the sphericity of the femoral head. You can see the beautiful exposure that we have for our camera section. With the pano scope, we're able to see very easily the anterior extent of our resection as well as the posterior extent. This wide field of view really helps in ensuring an accurate resection, both in terms of ensuring that you don't over resect or under resect the Cam lesion as we continue with our resection. You will see that the nano needle allows us to ensure that we've got a nice contour and are able to restore the normal sphericity of the femoral head neck junction through the use of the Pana scope. We can reduce the need for intraoperative radiographs and therefore reduce the amount of radiation for the surgeon or staff, as well as the patient. With use of the scope, we can see a wide field of view, allowing us to see both the anterior and posterior extent of our resection. The addition of the nano needle allows the additional advantage of a horizon view that as we range the hip through a dynamic exam, we can ensure that there's been an adequate resection without residual impingement. Additionally, we can see that there's been appropriate resection as well as the labor repair stable. And we've successfully restored the suction seal of the hip.

Hip Labral Repair and Cam Resection Using Dual-View Imaging With the Synergy Vision™ System

This animation reviews a thoracic transforaminal approach for discectomy procedures, which is performed with the Synergy Vision™ imaging system and a spine-specific endoscope. It also highlights the unique WishBone™ instrument handle, which is designed for improved ergonomics, and FlexTip electrosurgery probe.

Spine

Thoracic Transforaminal Endoscopic Discectomy

The endoscopic thoracic transforaminal discectomy approach from Arthrex is an ultra minimally invasive surgery ideal for patients with certain thoracic disc herniations. In this procedure, the endoscope is used to assist in the approach for access and visualization. The patient is placed in the prone position using an orthogonal AP fluoro image. Draw a line at the midline. Then draw a line through the center of the disc. Next, from a lateral view, mark a line to the front of the disc space, giving an orthogonal view of the disc. Mark the apex of the rib, which is the lateral boundary for making the incision point and needle insertion. Insert the needle at approximately 35 degrees, depending on the location of the disc. Pathology. Make an incision along the along the introducer needle. Next, insert the guidewire and remove the needle. Insert the dilators while rotating. Next, insert the cannula while rotating with the open side towards the foramen. Remove the dilators and insert the endoscope. Use the cup graspers and the flex tip bipolar probe to identify bony landmarks and remove soft tissue to expose the foramen. Use a bird to resect a portion of the inferior pedicle to create a working channel for the endoscope and cannula. Next, if necessary, to reach the midline, create a trough from the superior end plate to the inferior end plate through the disc and above the disc in the vertebral body. When the working channel has been created, the space underneath the cord allows for removal of any fragments ventral to the cord using a downward and outward motion. Confirm the decompression has been completed using direct visualization and palpation. The endoscope and cannula are then removed, followed by wound closure and placement of a JumpStart bandage.

Thoracic Transforaminal Endoscopic Discectomy

Walter R. Lowe, MD (Houston, TX), demonstrates a meniscal allograft transplantation using the SutureLoc™ implant for soft-tissue fixation of the posterior horn and bone plug fixation of the anterior horn.

Graft Preparation and Passage for a Meniscal Allograft Transplantation Using the SutureLoc™ Implant

Hi, this is Doctor Walt Lowe from Houston, Texas. And today we're going to show a medial meniscal transplant. You can see here that we've already sort of prepped this knee. And I'll give you a little guided tour here through it. We've completed the meniscectomy around the entire circumference of the meniscus. As we go through there. I've already prepared the bed where we're going to put it in, but I'll show you a little more about that in a second. It's very important as we go through this to most important first step is just getting the position of the posterior horn and the anterior horn. Right. So I've prepared this area, but I think good to just show it again in that taking a little arthroscopic curette and just made a footprint here for the bony attachment posteriorly. So I still use bone both anteriorly and posteriorly, but just a little wedge back here. So I make a footprint and you can tell. And I think this is a very good view. I'll kind of look at it with the NanoScope through a 70 degree view. You can see that this is right where the medial meniscus root attaches posteriorly. So it is a little anterior to what you would expect it is. And if you don't recognize that, you will start the extrusion process of these transplants just by putting it in the wrong place. So once I've prepared that with the Curette and got it ready, then the PoweRasp really does a nice job of flattening this surface out so that my bony piece will fit down in this prepared area. So just a quick review. Here's where we're going to put the posterior plug back there pretty much out to the rim all the way around. Flip the scope around and we'll see all the way anteriorly. Now that we've had the posterior footprint prepared and ready to go, We're going to move to the back table and I'll show you how we prepare the meniscal transplant graft. Get getting ready for his implantation. Okay, so now we're at the back table and going to be preparing the medial meniscus transplant graft for us to implant later. We've done a little bit of work ahead of time. We've prepared the anterior plug. You can see that I still use a bony socket anteriorly. It's fixed with a number two FiberLoop that is basically loop up flipped over and tighten down. So you can see that suture fixation. You know we've got the bone plug for the anterior horn prepared already. Kind of flipped this over to show you we've marked the undersurface of the transplant graft with the P that just says posterior. So we know that goes in back and just little dots along it. So we always know which side goes up and which side goes down. That sounds silly, but it can really get confusing sometimes in the knee as you're trying to reduce the meniscus. So those little marks become very helpful. Now we're going to focus on the posterior bone preparation because this is what's different. This is going to be a little thin bony wedge that we can use the SutureLoc to pull down onto the surface posteriorly where it goes. So we still maintain some bony fixation, but have the fixation of the SutureLoc right up underneath the subchondral bone. So we can do osteotomies. We can do all kinds of other things with this without fear of disrupting our sutures. So let's go ahead and prepare that posterior bone you can see marked out sort of the outlines of how we want to fashion this bony component of the transplant. And we've marked it big. So we can start with something we can work for, and then kind of sculpt it down to match the area on the posterior part of the tibial plateau, where it's going to fit in as the posterior root attachment of the medial meniscal transplant. Now you can see we have sort of our bony piece ready to shape up to put in. And it's really important, I think, you know, just as advice on how to do this, we try to get this done while they're bringing the patient back to the room, putting them to sleep, so that by the time we're actually ready to start the case, that this is already done and it hasn't delayed your case if you're having to prepare this by yourself. So this is sort of the base we're working from. But to do what I want to do with it, it has to be a lot thinner. And so this will just end up just being a very thin, bony piece that you can actually pass needles through, pass needles with a Scorpion through to pass your sutures. Because to have this pull this piece down into the bed, we're going to put it, it has to be a mattress type suture with both of the SutureLoc sutures. So we're going to now we're going to take what we have to work with and move it down to the final implant. So we're in the final stages of getting this meniscal allograft transplant ready to implant. And you can see we've really thinned down this wafer. And this is going to be the size that we implant for our posterior root attachment. And just finishing up, thinning this out and getting it very smooth with the bur. Okay. This is the final prep of the graft. And we're ready to take the next steps to implant it in the knee. You can see the anterior horn is a typical cylindrical plug into a socket up front. And then this very thin wafer in back will be what we use the SutureLoc to sink down into the prepared bony bed for it as the posterior root attachment. And while we're waiting to implant this, we'll put a few drops of ACP on each bony piece, getting ready to implant it. Once we're ready. Okay, so we're ready to put the transplant piece in. And so now I just have to get some sutures ready to help me pull it in. So you can see I've sort of previously placed a blue suture, a TigerWire, and another suture up here at the front. Those are all just to help me reduce. And if I like these two posterior ones, I'll tie it together at the end. If I don't, then we'll just place our other, you know, a meniscal repair sutures as we go. And so we're just attaching this loop to a similarly placed blue suture on the transplant. And then we'll just pull that through. And we can clamp this. You always got to make sure you don't have any little soft tissue bridges. So I'll just do these one at a time. And then we'll attach the TigerWire to it with the second suture in. And then the last. So once we have these sutures passed, and this is just to help us manage the tissue of the transplant as we reduce it into the joint. Step one here is we'll start with our SutureLoc. I always go blue first, white second. And that way I kind of always know what I'm doing. We see the posterior side of the implant here versus the top here. And we're going to come up over and down. So you can see the wafer was thin enough that I could pass my suture through with a Scorpion. And I think that's sort of the test. Now we're going to do the same thing and turn the Scorpion upside down and go back. Through it. So we create this kind of horizontal mattress suture through it. So now we've loaded it to the passing suture. And now we'll sort of provisionally reduce this suture. You can see this transplant piece always stays very close to the little arthrotomy here, because you just don't have much room to get all this done. So now we sort of have these two mattress sutures in this little thin bone wedge. Will attach the next one, and then we'll show passing the graft. You want to get this passed completely through for fixation, but you don't want to pull it too tight. So now we're just going to kind of shuttle this down in. You know now we've reduced this posterior piece into its bed. You can see I can sort of if you focus up close on that route, I'm really pulling hard. And I got no motion there. And then we'll come in and try to pull it back. You see, I got it down really good. Try to loosen it up. I'll retension again and focus back on that route and see. Even doing that, I got very little movement. Second time around, we can sort of flex and extend the knee. Usually I'll cycle a few times, go back and look at it. Retention again just pulling on blue and white outside here. And so that's down and I think looks beautiful. So now we can see how the meniscus reduces with our two more posteriorly placed sutures. You can see this meniscus without really much done yet is already pretty well reduced. So it's really important right now that we get the anterior bone plug placed. Because that's going to let us bring the capsule to the meniscus rather than take the meniscus out to the capsule as one of the many strategies to decrease the extrusion of this. Now we have the the anterior piece of the meniscus transplant that we're going to drill the hole for. So there's always sort of a judgment of reducing. And much like how posterior and then moving a little far anterior on the back of that eminence is for the posterior horn. The anterior horn goes way more lateral than you would think, but your meniscal transplant has to match that deal, and you can see how it doesn't go here. It goes way over there. Okay. And that'll really help us reduce the extrusion down the line too. So I've already drilled the socket for the anterior bone plug. And then just with a little two four drill to score the cortex, I've passed the lasso up into that. And now we'll load the anterior bone plug on this lasso. And that'll help us seed it and fix it anteriorly. And I'll just start reducing this in. This is a very tight fit. And then just tap that in gently. Good a little more. So now you see the the bone plug is seated in its socket. A band can pass underneath so you can see it better. And then I'll just use dog bones. Swivelock sort of your choice to fix it on the on the anterior surface of the tibia. Okay. So we've put some sutures all the way around. Now we still have the anterior horn left to fix, which you can put sutures in from inside out from outside in. You know, use anything you like to fix that anterior horn. Pretty easy. You can see, after all that manipulation, there's poster horn again with SutureLoc will retension it. So go ahead and pull blue white. You know, and I think the important thing with this is just tension retention. Tension retention. So I think that looks beautiful at the end. Once we have things fixed, then we'll drop our needle in and get in and around the bone plug and deploy some ACP we previously soaked the graft in.

Graft Preparation and Passage for a Meniscal Allograft Transplantation Using the SutureLoc™ Implant

Rajit Saluja, MD (Franklin, WI), provides technique pearls for treating a bone marrow lesion of the knee with the IntraOsseous BioPlasty® (IOBP®) procedure. Dr. Saluja mixes AlloSync™ Pure demineralized bone matrix and Angel® concentrated platelet-rich plasma from bone marrow aspirate (cPRP from BMA) to treat these defects.

Treatment of a Knee Bone Marrow Lesion With the IOBP® Procedure

I'm Doctor Rajit Saluja, and today we're going to perform an intraosseous bioplastic of the medial femoral condyle. This patient has a bone marrow edema lesion in the medial femoral condyle. We have identified it on an MRI scan. And typically, as we do this procedure, we've already obtained the bone marrow aspirate from the pelvis, typically from the posterior superior iliac spine. This aspirate we typically obtain about 60 cc's. And we use the Arthrex Angel apparatus to obtain the concentrate. This five CCS is then mixed with five cc's of AlloSync, which is the demineralized bone matrix. To that, we combine a cc of contrast which allows us to visualize the injection procedure. Under fluoroscopy, we have the demineralized bone matrix and the bone marrow aspirate concentrate mixture. We've divided them into five one cc syringes. I like to use one cc syringes because if you have multiple lesions, it's easier to subdivide how much total material you have and you can allocate it depending on where the lesions are the largest. We'll start with having our leg in extension. We already completed the arthroscopic part of the procedure. Meniscal debridement has already been carried out. We'll bring the fluoroscopy on an AP view. We'll typically take a spinal needle, find the entry point and take an image. At this point you can see how we're at a good spot here on an AP view. We've already identified the entry point for the injection site, and at this point, we'll go ahead and make a small nick with an 11 blade. This is the Iabp closed tip delivery cannula. I typically use the closed tip because it allows me to fill the lesion more circumferentially. I like to go parallel to the joint line. As you can see, the ends are pointed downwards. Here we'll take our first injection syringe. We'll inject that into the delivery system. Now we'll gradually impact this in. You can see some of the material is coming out on the image. Then I'll rotate the device and get some of the more anterior portion filling. And we'll rotate it some of the posterior portion. We'll withdraw the delivery system a little bit. We'll take another one CC syringe. On the image on the right you can see how the lesion has been filled with the bone marrow concentrate and the demineralized bone. You can get a lot of views at this time. And you can save the images. And you can see how the lesion is filled to your desired goal.

Treatment of a Knee Bone Marrow Lesion With the IOBP® Procedure

At the Comprehensive Shoulder Arthroplasty course, Asheesh Bedi, MD (Ann Arbor, MI), presents the challenges of shoulder arthroplasty and discusses peer-reviewed literature that supports the use of preoperative planning software.

Arthroplasty Shoulder

Glenohumeral Joint Arthritis: Literature Review on Preoperative Planning for Shoulder Arthroplasty

OrthoPedia: Glenohumeral Joint Arthritis: Literature Review on Preoperative Planning for Shoulder Arthroplasty

Mazda Farshad, MD (Zurich, Switzerland), performs a posterior endoscopic foraminotomy at the C4-C5 level.

Cervical Foraminotomy

My name is Mazda Farshad from Zurich, Switzerland. We are performing a posterior endoscopic cervical foramina. The patient is positioned like for a standard posterior approach of the cervical spine. You can use a Mayfield frame to fixate the head. Fluoroscopy is positioned 90 degrees to the patient. This is cranial. This is caudal. So we start first by palpating the midline and drawing the midline. Once the midline is identified by palpation and the line is drawn, we make a lateral fluoroscopy shot to identify the level that we're aiming at here we're aiming at levels four five. So we want to aim towards the disc of the level that we're aiming at. That would be level four, five and 90 degree to the spine. We can then insert the needle. The needle should be inserted approximately one centimeter lateral to the midline. This will allow that later on we can have a nice view on the foramen. Now we want to aim a little bit higher. Approximately 2 to 3mm higher to be able to palpate the upper lamina. That would be the lamina number four here. Once we're happy we cut the skin and do. Skin incisions in a vertical direction from cranial to caudal. So that conversion to open surgery would be possible at any time. Once this is done, the K-wires is installed. Make sure that the K-wires is vertical to the floor 90 degrees. Otherwise, adjust the patient and the table. By Trendelenburg or anti Trendelenburg to achieve this position. After that the dilation is done. This can be done stepwise or directly using the switching stick already with the switching stick. You can palpate the upper lamina Over the switching stick, the canyon can be inserted. A fluoroscopy shot will verify that we're on the right level with the switching stick inside, the lamina is freed up from muscles by going from medial to lateral using the sharp edge of the cannula, then the switching stick can be removed. Now we see the position of the cannula aiming at the disc four five, where we want to be at in approximately 90 degree angle to the cervical spine. Once this is done, we could insert the endoscope. For purposes of visualization, we will now do an AP view. The AP view can be used if one is unsure about medial lateral position of the cannula. The endoscope can now be inserted. And make sure to control the cannula so that it doesn't move. And now the soft tissue can be removed with a large pituitary. So the soft tissue is removed and we start to see the upper lamina C4, the bone of the upper lamina. Here we remove a little bit more soft tissue and identify the lower lamina of C5. Here with the bipolar we can clean up the soft tissue nicely and palpate the upper and the lower lamina. So the upper lamina here the medial border the lower lamina. And then we start to identify a V form. This is the so-called V sign formed by the upper lamina and the lower lamina. And this is the entrance to the spinal canal. Here we already see the ligamentum flavum. So now we want to turn the V into a U by using the burr. I usually start with the upper lamina and then we go. We proceed to the lower lamina. Make sure to remove enough of the lower lamina. No pressure on the burr, but more on the cannula if you want to manipulate the position. So now we have removed the bone and converted the V to a U. A little bit of the upper lamina. More on the lower lamina so that actually the ligamentum flavum, the attachment is disconnected to the lamina. Here we see we are already in the spinal canal. And we can start dissecting the ligamentum flavum from caudally to cranially. Once we have disconnected the ligament from the lower lamina, we can use a kerrison to remove it in a stepwise fashion. Before that, you might want to go more lateral by removing more bone. So then we can change the view a bit to resect the ligamentum flavum. I use the kerosene for that. Make sure to turn the scope so that you verify that you're just removing ligament and nothing else. The aim is to visualize the lateral border of the dura. The best view to remove the flavum towards medial is from caudal to cranial, so you can turn your scope around 70 to 90 degrees to visualize the opening of the kerosene to be able to remove the flavum safely. The identification of the lateral border of the dura is extremely important in order to identify the nerve. Once we have identified the lateral border of the dura as seen here, we can basically glide up to the nerve root, and here the nerve root is identified here. We are now in the axilla of the nerve root. The same can be done from cranial to caudal. Identifying the shoulder of the nerve root as demonstrated here. So now we see the dura, the lateral border. The axilla of the nerve root at this condition would be accessible here. And the shoulder of the nerve root here we are pointing towards the foramen. So with the ball tip we can palpate also the pedicle. Here we are palpating nicely the pedicle of the lower vertebra which is c5 in our case. The ball tip can also be used to carefully palpate into the foramen. Once this is done the foramen can be visualized By turning the scope facing the foramen. Once the nerve root is identified, we have to look into the foramen. For that, we position our canal either on the upper or the lower lamina, and turn the cannula and the camera in order to visualize the nerve, as demonstrated here. So now we're looking into the foramen, and we can use our kerosene to remove some more bone. You can always turn your camera to be able to have a better look for verification of a full decompression. Use your ball tip to palpate along the nerve root. So here we have the nerve root and the foramen which is now freed up. This can be also visualized from another view looking how the cranially. Here again we have the lateral border of the dura. The axilla. And here we are in the foramen. And now I'm palpating all through the foramen, making sure that the foramen is fully free and the nerve is decompressed. Once the decompression is completed and you have verified that visually, and also by palpation, you can pull out your camera and your cannula and close the skin with 1 or 2 stitches. Posterior cervical endoscopic approaches allow decompression of the nerves by foramina or and or discectomy. This is not a beginner level surgery for endoscopy. It allows to avoid acdf in many cases, can usually be performed within 45 to 60 minutes in an outpatient setting.

Cervical Foraminotomy

With the TensionTight™ button, perform a knotless onlay biceps tenodesis using an arthroscopic suprapectoral or open subpectoral approach. The button’s locking jaw lets the suture slide easily in one direction to reduce the tendon to the bone while locking in the opposite direction to secure the tendon against the humerus.

Subpectoral Biceps Tenodesis Using the TensionTight™ Button

Make a 2 to 3 centimeter incision in the axilla at the inferior border of the pectoralis major. Bluntly dissect to identify the pectoralis major and the long head of the biceps tendon. Retrieve the previously surmised biceps tendon through the incision. Create a loop and tack whip stitch by cinching the number five FiberLink around the tendon approximately two centimeters from the musculotendinous junction, and then passing the tail through the tendon distal to the loop. Load the tail of the FiberLink into the button loader. Pull the tab to shuttle the suture through the button, stopping just before the loop enters the locking jaw. Place the drill at the desired location on the bony surface of the proximal humerus, and drill a cortical tunnel using the 3.7mm spade tip drill. Insert the button into the tunnel. Turn the threaded inserter counterclockwise to release the button. Remove the threaded inserter. Pull on the suture to flip the button in the canal. Remove the inserter shaft. Once the button is deployed against the near cortex, pull on the free suture limb to reduce the tendon under the bone. Cut the excess suture to complete the tenodesis.

What's NewJAN 7

Osteochondral Flap Repair System With Chondral Dart™ Implant

What’s New This Week and Prior

JAN 6

Inlay vs Onlay for Knee Repair Surgery: What Does the Data Tell Us?

JAN 5

Upper-Border Subscapularis Repair Using the Double-Loaded Knotless FiberTak® Soft Anchor

JAN 4

iBalance® UKA Technique

JAN 3

OrthoPedia: Treating Bone Marrow Lesions: IntraOssesous BioPlasty® (IOBP®) Technique