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Pitcher's Recovery

Rachel M. Frank, MD (Denver, CO), treats a patient with a full ACL tear using the all-suture TightRope® SB implant and a quadriceps tendon autograft. Dr. Frank also discusses her use of the QuadPro™ tendon harvester and reviews graft preparation steps.

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English  - en

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Live Case: TightRope® SB Implant and Quad Autograft for ACL Reconstruction

Speaker  Hey everyone, it's doctor Frank here. We're getting ready for a busy day of surgery. Our first case up is a patient with a complete ACL rupture. You can see here on the MRI complete ACL tear, pivot shift, bone bruise pattern. An amazing candidate to undergo ACL reconstruction. Our game plan is an ACL reconstruction using quad tendon autograft with the TightRope soft button with internal brace. Let's go operate. We begin with the quadriceps tendon Autograft harvest. We do this by making an incision approximately 2 to 3cm in length, starting approximately one fingerbreadth above the superior pole of the patella. After we incise through the skin, we'll get through the subcutaneous tissue and we'll get down to the peritenon of the quadriceps tendon. Then we'll use the QuadPro harvester to mark our starting point on the superior pole of the patella. We'll then use a number 15 blade scalpel to dissect the distal aspect of the quad tendon in a full thickness fashion. Once we've dissected the tendon for about 3 to 4cm, we'll whipstitch the distal aspect of the tendon. Next, we'll use the QuadPro harvester to go ahead and harvest our quadriceps tendon, aiming toward the superior aspect of the tendon in 360 degree fashions will aim for a depth of about 65 to 70mm in most patients. Once we've achieved our desired length 65 to 70mm, we'll use the push rod to amputate the quadriceps tendon proximally. Speaker  You can see a nice full thickness quadriceps tendon harvest. And then we'll go to the back table. And this is where the soft button technology will really shine. You'll use the graft clamp like you would with any other FiberTag TightRope, and you'll prep the TightRope onto the graft the same way that you would prior to the soft button technology going up and down through the FiberTag. But now we're going to really see what the FiberTag TightRope soft button technology is all about. The yellow portion that you see is the button that's replaced the metallic cortical button, and by pulling on the included TigerWire and FiberWire sutures, we can elongate the button so that it'll pass through a cortical hole. We'll do the same thing on the opposite side of the graft. And in this case we're showing the internal brace. So this will be used on the femoral side of our graft fixation. Next we'll compress the graft and the compression tube's on the back table so that we can get as tight of a draft as possible within our tunnels to get a nice solid ACL reconstruction. Maintain the graft on tension on the back table with a vancomycin soaked saline sponge. After the graft is prepared, we'll get back to the knee and start our preparations for ACL tunnels. Speaker  I like to drill my femoral tunnel through an Anteromedial portal approach with the knee hyperflexed. We'll drill our drill pin in place, and then we'll ream with a low profile, rigid reamer to the depth of about 22 to 23mm. The size, depending on the size of your graft. And we'll go ahead and pass a passing suture. Next we'll assess the integrity of our femoral tunnel from the medial portal. Next we'll go ahead and drill our tibial tunnel using the FlipCutter. This allows us to create an all inside ACL reconstruction using the low pro rigid reamer on the femur and the FlipCutter on the tibia. We retro reamed to a depth of about 25 to 30. Again with the size based on the size of your graft. We'll go ahead and pass a passing suture. We'll collect both passing sutures for the femur and tibia. And now we'll get ready to pass our graft. Our graft has been previously prepared. Soaking with vancomycin soaked saline under tension on the back table. Now we'll get ready to go ahead and pass our graft. And first we'll pull up into the femoral tunnel. Through the femoral tunnel, we'll pull our leading blue FiberWire sutures, as well as the TightRope white sutures through that cortical hole on the femoral tunnel, which can be 4 or 4.5 millimetres, depending on your preference. Lots of options for you. Speaker  You'll see we're elongating the TightRope soft button by pulling on the blue leader sutures out laterally against the white TigerWire sutures out the medial portal, and that elongates the button. You see me switching my scope over to the medial portal to watch that soft button go up into the femoral socket, and then go through that cortical hole on the lateral femur. Again, you're drilling that typically with a four or a 4.5mm reamer, or you're using your FlipCutter to make that hole on the lateral cortical wall. Here, we're going to watch that TightRope go into that cortical hole, and then flip just on the lateral cortex of the femur. And we're doing that by keeping the button elongated by pulling on those TigerWire and FiberWire sutures. Now that we've flipped our button, we can pull back on the graft InternalBrace or both, as you see me doing here. And really make sure that button is tight against the lateral femoral cortex. I like to take an X-ray intraoperatively with the mini fluoroscopy to confirm the appearance of the button. And the versatility of the soft button is that if I don't like anything, I have an opportunity to adjust the soft button before I tension my graft. We like the position of our button. We're happy with everything. So now we'll get ready to bring the graft up into the femoral socket. Speaker  Here, I'm marking the TightRope sutures with a sterile marking pen so that I know I'm keeping my TightRope even. Next, we don't have to worry about the blue leader sutures or the TigerWire trailing sutures. Those are done at this point, and we're simply going to use our tightrope sutures to shuttle our graft up into the femoral socket. I like to get about 15 to 20mm of collagen up into the socket. And then I know that I have a really nice biologic tight fitting construct in the femur. Next, I will elongate the soft button by pulling on the blue leader FiberWire sutures against the white trailing TigerWire sutures to elongate that button. So now that we've secured the graft into the femoral socket, we'll go ahead and pass the graft into the tibial socket. We will use the FiberSnare that we previously collected out the Anteromedial portal to pass all of our sutures on the tibial side of the graft, including the InternalBrace FiberTape sutures down the tibial tunnel. As you can see here, I've already passed all of those sutures down. So now we're pulling all of the sutures down the tibial tunnel to maintain the elongation of the soft button. We'll leave our TigerWire sutures out the medial portal and we'll pull opposite those the leading blue FiberWire sutures as you see here just like we did on the femoral side. Speaker  And then we'll pull that. We'll pull tension on those two sutures, and then we'll be able to pull our button through that tibial tunnel through the FlipCutter hole. Next, we'll discard our TigerWire sutures because we no longer need them, because our buttons are where we like them. Once we've secured our graft into the tibial socket, we'll go ahead and cycle the knee 10 to 15 times, maintaining tension on the graph the entire time. And then we will begin our tibial fixation. Here I'm showing the features of the TightRope soft button. We're elongating the button using the TigerWire sutures against the FiberWire sutures. We no longer need to do that at this point because the button is outside the cortex. But just illustrating how this works. Once you're done with the elongation of the button, you can discard the FiberWire and TigerWire sutures as you see here, because we no longer need to elongate the button. Next we will go ahead and tension our ACL graft just a little bit. Not all the way because I like to tension my internal brace first. But here I'll get the button down about 8,090% just basically. So it's resting on the cortex. But I like the graph to be tensioned last. So we'll do our final tensioning later. Next we will go ahead and secure our internal brace FiberTape sutures. Speaker  We'll drill. Then we'll tap the cortical bone. And then we'll place the FiberTape into a 4.75 SwiveLock suture anchor. And we'll get that down just distal to the tibial tunnel aperture. Now you can see I'm final tensioning the graft using the TightRope soft button on both the tibial side, and I have the opportunity to do that on the femoral side as well. I typically do that with the knee at about 10 to 20 degrees of flexion, and I do my internal brace at full extension or full hyperextension. Next we'll go back to the scope. We'll make sure we love the appearance of our graft. We still have opportunity to retension our graft on either the femur or the tibial side using the TightRope soft button technology. You can't see the internal brace FiberTape, but they are resting behind the graft in this case. We'll then final check our exam with an intraoperative lachman and we really have no motion in this case. Just finished up with surgery. Acl reconstruction quad tendon. Autograft. Fibertag. Tightrope. Soft button on both the femur and the tibia. Internal brace. As you can see here on the intraoperative fluoroscopy X-rays, we can see the TightRope soft button on both the femoral and tibial sides. Looks amazing. Super excited about this technology and can't wait to see this athlete get back to sport.

Live Case: TightRope® SB Implant and Quad Autograft for ACL Reconstruction

Lee Hunter, MD (Columbia, TN), presents the Arthrex Elbow Fracture Plating System, using a dorsal olecranon fracture plate to reduce the fracture. The elbow is positioned using the ElbowLoc® arm positioner, allowing the surgeon to complete the surgery in supine, as shown in this video, or lateral position. KreuLock™ locking compression screws allow for compression across the fracture and stability in the plate.

Hand and Wrist

Olecranon Fracture Fixation Using the Arthrex Elbow Plating System

My name is Lee Hunter. I'm an upper extremity orthopedic surgeon with Tennessee Orthopedic Alliance. So we've chosen to repair this elbow fracture using this elbow lock arm positioning system. And it's perfect for a lot of things elbow related, but particularly olecranon fractures because, say, for example, now we have this patient's arm at 90 degrees, and there's some inherent tension on this proximal fragment from the triceps. How you reduce that tension as you extend the elbow. And what that does, it just makes maintaining the reduction a lot easier. Today we're using the six hole proximal ulnar olecranon plate system also offers a shorter straight two hole plate. Arthritis also offers extended versions of these proximal ulna plates, all of which really nicely mirror the bow of the proximal ulna. Now, we've got our provisional fixation. My assistant's not really doing anything because elbow lock's doing all the work. We generally start with this oblong, most proximal compression hole. It is placed by cortically. You're well anterior to the coronoid process. We've got these nice ratcheting screwdrivers with an ergonomic handle which is really nice. Generally the oblong screw first and then one of these proximal screws just kind of dealer's choice on those just to make sure you got both fragments stabilized. So this is what I like to call a point and shoot guide. It could also be called a calibrated drill guide. And it's really done a fine job with this. As you drill and you advance, the single etching actually refers to the shorter screw lengths that are in this image on the top. And as you keep drilling and you advance the drill bit, you'll notice a double line comes in and that actually references these longer screw lengths. So as you put in these proximal screws, you just keep in mind where your joint is. Now we can see it through this window that we've made. Be cognizant of that with these proximal screws. What I'm trying to do with this is I'm trying to aim obliquely, staying in the proximal ulna, but engaging this good coronoid bone up here because a lot of times the bone just distal to that is not quite as good a bone as in the coronoid process. This is what all these proximal screws are trying to aim and get up in. I would like to point out, as you're exposing, these proximal ulna fractures, leave as much soft tissue attached to the bone as you can. I've left this sleeve of soft tissue here purposefully because my ulnar nerve is protected from that. Always be aware that sometimes there's metaphyseal comminution here. So there is. I would encourage you to strip this more, to expose more where you can actually see the interdigitation of the fracture fragments. And after we after we lock the plate, after we put this screw in, we'll have the plate secured to the distal fragment. And we'll image and make sure that we're happy with our reduction and our proximal most screw. And I would suggest that before you get too committed to this kind of temporary fixation that we have, that you bring in fluoro and make sure you're happy with your reduction and your placement of these initial screws, particularly this proximal screw, and how we image with the elbow lock system in this situation is you loosen the humeral collet, you just slip out the humeral brace, and the surgeon abducts the arm off the table, and you bring in fluoro from the side. If you notice this lateral view that we have the elbow, you'll see a few things. The plate fits really nicely on the back of the ulna, particularly proximally. There it does over the olecranon that proximal most screw, how it survives right under the joint surface and engages that really hard metaphyseal bone at the base of the coronoid. That's really what you're after. And that's my temporary fixation. Right below that, there's another screw that's going to mirror that course as well. And you can see really nice position of the distal screws. So now we're happy with our reduction. We know our plates right. We don't have to change anything. We can just place the rest of the screws. We've removed our provisional fixation. Now we're moving on to securing the plate to the proximal ulna. This proximal most screw is oriented relatively longitudinally. So this apical screw is actually going to be quite a bit shorter. You'll bump up against the articular cortex of the olecranon, but just don't perforate it. This is another one of those oblique screws that's designed to advance up into the metathesis of the coronoid. And keep in mind, as you begin to do this, you're after two cortices. If you feel four, you're in and out of the proximal ulna and into the distal humerus, which can easily happen. So maintain some awareness of where your joint is and the inclination of your drilling. So for the purposes of this presentation, we won't fill all the holes. But you get the concept a really nice reduction. We've got really good purchase for solid screws proximally and for distally. So we'll again for imaging we'll slip off this humeral support. And the surgeon or their assistant will just abduct the arm off the table. Bring in fluoro from the side. So now this is our final reduction. This looks really nice. You know the fracture is reduced. All the screws have a really nice length. Those two oblique proximal screws that just go kind of almost juxta cortical engage that coronoid fragment proximally. That's really what you're after. And I particularly like that longer first proximal screw just immediately distal to the fracture. How that really engages the bulk of it. So I'm really happy with how our X-rays look. I inserted this proximal most screw using a variable angle guide. But alternatively you can use this fixed angle guide threaded in. And it gives you the longitudinal orientation that some people refer to as a home run screw. So here are our final images. Again. Really nice fit of the plate to the bone. The screws are all placed really nicely. You can see the home run ish type screw there proximally, just a butting up against the distal cortex which is really what you want.

Olecranon Fracture Fixation Using the Arthrex Elbow Plating System

This animation demonstrates the steps of the interlaminar approach for a discectomy procedure using the SynergyID™ 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

Interlaminar Approach for Endoscopic Discectomy Procedures

Arthrex interlaminar endoscopic approach for a discectomy is an ultra minimally invasive surgery ideal for patients who have been diagnosed with a paracentral lumbar disc herniation. In this procedure, the endoscope is used to assist in the approach for access and visualization, place the patient in the prone position and use a c-arm to verify the correct level being treated. Using both AP and lateral images based on the preoperative MRI, use a six step approach to complete the procedure. Step one the bulls eye. Use a switching stick to identify the entry point, which is the lateral aspect of the ipsilateral interlaminar window. Make an incision between 8 to 10mm through both the skin and fascia. An alternative method utilizing serial dilators can also be used. Insert an introducer needle. Remove the stylet and pass a guidewire through the cannula and then remove the cannula. Insert serial dilators over the guidewire until the appropriate diameter is achieved. Continue utilizing dilators for steps two and three. Step two the click. Use fluoroscopy and insert the switching stick into the interlaminar window and on top of the ligamentum flavum. The tip of the switching stick is used to traverse the inferior edge of the lamina in a caudal to cranial direction. This action should create a tactile click, as the tip of the switching stick comes over the edge of the lamina. Insert the cannula over the switching stick, then remove the switching stick and insert the endoscope. The surgeon may choose to connect the cannula holder to aid in maintaining the trajectory. Connect the holder to the cannula prior to the switching stick being removed. A depth stop may be attached to the endoscope to maintain the depth within the cannula. Arthrex offers a unique WishBone handle design that allows for improved ergonomics and mobility of the instrument by the surgeon. Step three cleaning the trampoline. Once the endoscope has been inserted, insert a series of grasping instruments and the electrosurgery probe through working channel of the endoscope to remove excess tissue and coagulate blood vessels to expose the ligamentum flavum. Step four. The black hole. Use both the straight and angled scissor punch instruments to resect the ligamentum flavum, and to gain access to the spinal canal, which will present itself as the look of a black hole. This is caused by irrigation fluid moving into the spinal canal, creating negative pressure on the Carta equina, thereby expanding the epidural space. Step five. Identify the edge of the nerve root. Once a sufficient amount of ligament has been excised, slowly advance the cannula through ligament and into the spinal canal, with the bevel of the cannula facing medial and allowing the edge of the nerve root to be clearly visualized. Step six. Retract and protect. Mobilize the nerve root by using instruments such as a blunt tip, elevator nerve hook, and articulating probe to release any scar tissue that may be adhered to the dura. Once the nerve root has been mobilized, advance and rotate the cannula to retract and protect the nerve root. With the nerve root retracted and protected, use a blunt instrument, such as an elevator, to put pressure on the annulus, releasing the nucleus. Pulposus. Next, use grasping forceps to extract the exposed nuclear material. Use the Electrosurgery probe to ablate nuclear material and minimize the annular defect. Once complete, slowly remove the scope and cannula.

Interlaminar Approach for Endoscopic Discectomy Procedures

Designed to be deltoid-sparing, the Arthrex Anatomic Proximal Humeral Plating System delivers versatile fixation with 7 plate lengths (92-265 mm) to address a wide range of fracture patterns. Featuring variable-angle locking screw options, KreuLock® technology, and integrated FiberTape® cerclage button capability, this system is designed for strength, flexibility, and efficiency.

Arthroplasty Shoulder

Arthrex Anatomic Proximal Humeral Plating System

Speaker  The Arthrex Anatomic Proximal Humeral Plating system is designed to be a limited contact deltoid sparing plate, aiming to avoid taking down the deltoid insertion on the humeral shaft during implantation. This plate features variable angle locking and compression screw technology to provide a streamlined, reproducible reconstruction of proximal humerus fractures. The proximal humeral plating system includes 14 site specific anatomic proximal humeral plates. Seven plates for left shoulders and seven plates for right shoulders. Plates are three whole to 15 whole, with length starting at 92mm and ending at 265mm. Anatomic plates feature a divergent screw pattern with a choice of 4.0mm cancellous or 3.5mm reinforced variable angle locking or KreuLock screws in the head, and a five millimetres compression slot in the shaft, 3.5mm cortical screws are accepted in the first five screw holes of any anatomic plate. Further, distal OR plates that are seven hole or longer screw holes, except 4.5mm cortical screws or 4.5mm FiberTape cerclage buttons. The Arthrex Anatomical Proximal humeral plate is specifically designed to be deltoid sparing, curving anteriorly before the general region of the deltoid insertion on the humerus. Suture eyelets in the bend are intended to assist with soft tissue repair. The proximal humeral plating system requires two instrument trays for clinical use. The designated proximal humeral tray, as well as a general instrument tray. Begin the procedure by using the T 15 screwdriver to secure the alignment guide to the plate. Confirm the plate position by placing a two millimetres k-wire through the hole on the superior aspect of the alignment guide. Speaker  Using the 2.5mm drill guide and 2.5mm drill bit. Drill through both cortices of the oblong hole in the shaft of the plate. Use the depth gauge to determine appropriate screw length and insert a 3.5mm cortical screw. Next, confirm appropriate plate positioning by placing a 1.6mm k-wire through the drill guide. Confirm the k-wire position using fluoroscopy. If using the 3.5mm reinforced variable angle locking OR KreuLock screws, insert the 2.8mm locking drill guide or use the freehand drill guide if using a 4.0mm cancellous screw. Use the 2.5mm instrumentation. Ensure that the drill does not perforate the far cortex. Kreulock provides interfragmentary compression through a variable thread pitch of the screw. The lateral plate will allow for screws to be placed up to 12 degrees radially. From the central axis of the locking hole. Insert the desired screw using the T 15 driver. Repeat the previous steps for the remaining proximal locking screws and confirm appropriate fixation and reduction using fluoroscopy. If additional compression or plate reduction is needed, distally insert the reduction bolt by cortically through a locking drill guide. Thread the compression onto the reduction bolt until the nut contacts the drill guide. Continue turning the nut clockwise until the desired reduction is achieved. If desired, FiberTape. Cerclage. Sutures may be applied prior to placement of the plate or directly into the plate construct using the 3.4 or 4.5 millimetres cerclage buttons inserted into a plate shaft. Screw hole. Additionally, soft tissue may be repaired to the plate using any of the peripheral suture islands.

Arthrex Anatomic Proximal Humeral Plating System

Seth I. Gasser, MD (Tampa, FL), shares his firsthand experience with the Synergy Power™ system—highlighting how it streamlines workflow within a facility and why it is his preferred powered instrument solution in the OR.

Imaging and Resection

Dr. Seth I. Gasser Surgeon Testimonial: Synergy Power™ System

Speaker  Energy. Power has really changed the way our team works and functions. It's streamlined the work process, including setup times and surgical times with just two hand pieces. It covers our broad range of needs throughout any procedure. It's reliable. Powerful. Versatile. The frequent changes required often during surgery are quick and easy, with a unique design of the hand pieces. It's very easy for the scrub tech to make a quick change. I don't worry about them having difficulty, and my focus is really on the surgery and the patient because I'm confident that the equipment will work as it's supposed to. It provides a balance of comfort and performance. It has a lighter feel. And it's the kind of comfort that really adds up over the course of long, difficult cases. Arthrex has been a leader and innovator as long as I've been in practice over the past 33 years. They've answered all of our questions, guided our setups, trained the staff, and really made sure everything ran smoothly before we started. And this is just another example of how Arthrex has made it easier for me as a surgeon to treat my patients better.

Dr. Seth I. Gasser Surgeon Testimonial: Synergy Power™ System

Alan A. MacGill, DPM (Coral Springs, FL), reviews current literature surrounding lateral ankle instability treatments and discusses the significance of global ankle instability evaluation and management when treating ankle instability.

Foot and Ankle

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Lateral Ankle Instability: Literature Review on Lateral Ankle Instability Treatments and Global Ankle Instability Considerations

OrthoPedia: Lateral Ankle Instability: Literature Review on Lateral Ankle Instability Treatments and Global Ankle Instability Considerations

This animation highlights the features and clinical applications of the ApolloRF® H50 probe, anatomically engineered for precision in the hip, with efficient tissue ablation and coagulation.

ApolloRF® H50 Probe

ApolloRF® H50&nbsp;Probe

This animation outlines the steps for safely entering the joint using the Atraumatic Hip Access Disposable Kit.

Hip Joint Access Using the Atraumatic Hip Access Disposable Kit

The soft plastic material of the flush fit, a traumatic cannula system, and the blunt tip of the SafeCut. Capsulotomy blades are designed to reduce the risk of iatrogenic damage during access into the hip joint during hip arthroscopy procedures. Once the hip is distracted, insert a spinal needle and nitinol wire through an anterolateral portal to begin access into the joint. Use an obturator to dilate the capsule before inserting the plastic cannula. Insert the plastic obturator through the cannula by engaging the button, and place it over top of the nitinol wire with a slow, twisting motion. Depress the button behind the laser line and remove the obturator from the joint. Insert the NanoScope and bridge through the cannula to begin viewing the joint. Establish the mid anterior portal using the same steps used for the anterolateral portal to begin preparation for making a capsulotomy. Place the SafeCut blade through the cannula to begin the capsulotomy. The blunt end protects the cartilage from being inadvertently struck. Once the capsulotomy is achieved, replace the cannula through the incision to switch portals. Push behind the laser line to disengage the bridge from the scope and switch it to the mid anterior portal. Insert the blade through the anterolateral portal to complete the rest of the capsulotomy. The blunt tipped SafeCut blades come in straight and curved options with and without a handle, offering unparalleled versatility for safe joint entry.

Hip Joint Access Using the Atraumatic Hip Access Disposable Kit

Asif M. Ilyas, MD (Philadelphia, PA), presents a wide-awake endoscopic carpal tunnel release case using the NanoScopic™ release system.

Wide-Awake Endoscopic Carpal Tunnel Release Using the NanoScopic™ Release Disposable System

In this video, we're going to be going through an endoscopic carpal tunnel release using the Arthrex Nanoscope system. This is typically how I'll prep a patient with the arm just kind of out by their side. My patients are awake, so I'm often talking to them during the surgery, just kind of letting them know what I'll be doing. Generally, I will before we even get into the procedure room or the operating room, I'll inject in the preoperative holding area. And what I generally inject with is nine CCS of 1% lidocaine with epinephrine. But then I also add a cc of bicarbonate to that injection in pre-op. And I usually use a 27 gauge needle. And the logic behind that is that the bicarbonate cuts down on the acidity of the lidocaine so it doesn't burn as much. And the 27 gauge needle obviously is a smaller needle, so it's much more comfortable for the patient. That's my initial injection, which I'll replicate here. But then when we start in the in the operating room, I'll then add another ten ccs of 1% lidocaine as well with epinephrine. And so I'll generally have about 20 ccs injected. And I'll inject that while we're in the room once we're prepped and draped before we start. So that I can both augment the the anesthesia and the surgical site, but also to check to make sure that the patient is adequately anesthetized before we start the procedure. So again this is a 1% lidocaine with epi with the assumption I've already injected ten ccs preoperatively in terms of prepping and draping, I do a standard prepping and draping where we'll do a wash in preoperative holding, and then we'll do a chloraprep in the operating room. Standard drapes as applied here. But again the patient's awake so we don't cover them. So we just kind of put the drapes around them. They can engage or not engage during the procedure as they wish. Some patients wash, some patients don't. If they do watch, they often just watch the screen where we're doing the release in. In terms of the injection, this is important. So doing an effective injection for a case that's wide awake is central to the process. So one of the first things is to make sure that we inject the the proper site. So there's a couple of ways to identify where to place your incision. So first of all it's an endoscopic incision. So it's going to be a transverse incision. Now a couple of things to keep in mind. One is the risk crease which is approximately here we generally want to go half a centimeter or so proximal to that. And oftentimes patients have a nice risk crease right here just like this individual does. And then in terms of centering it we want to center it with either on over top of the palmaris longus tendon if we can see it, or in line with the third webspace of the of the hand, or sometimes just just checking for what we call the inner Thenar valley. So it's a rough rule of thumb, but that's ballpark where you want to center it. So if you look here, if you palpate the FCR tendon, the FCR tendon is easy to palpate. That's more radial. And the palmaris tendon is usually harder to palpate. Now if the patient's awake you can have them have them touch their thumb and small finger, and it'll bring the palmaris to the surface. Broadly, though, it's it's a central incision. So seeing here, here is that wrist. I'd like to exploit. It's about a one centimetre incision or about a half an inch incision transversely. Okay. So I'm going to mark it out some more. Again this should be centered above at the level of the palmaris longus or in line with the third webspace or in line with the inner thenar valley. So very simple. If anything, you're cheating. Slightly midline to ulnar is kind of the broad rule of thumb. Now, in terms of the injection, I'm going to place the injection here like I would in preoperative holding. So what I typically do is start the injection out to the side and outside the level of the hand. The hand is most sensitive. So we're at the wrist level here. Enter slowly. And the key is to enter and then inject slowly. Now the 27 gauge needle allows us to inject slowly because the needle is so small. And you'll notice I don't move the needle a whole lot. I'll inject 2 to 3 ccs right where I entered, and you'll see where insufflating the area where the incision is. Then that's the last time I'm going to enter a virgin territory. Now, going forward, I'll always enter where I've previously injected. So now I'm going to inject proximally. And I'm mostly superficial with this. And I'm injecting proximally. Now, as I do a little bit more proximal, I'll then go a little bit deeper slowly to get the median nerve as well. So I'm now below the antebrachial fascia. Then I do my distal injection where again I'm going to inject through area I've previously injected. And I always inject slowly. So I always make sure that the injection is going ahead. The flu is going ahead of my needle, and I'll put a finger here just to make sure that I'm getting adequate anesthesia distally. Obviously I don't want to put a needle in my own finger, but I'm making sure that I have enough volume distally. And that's the injection that I do in preoperative holding. And I'm going to do the same injection before we start. And and as we're doing this, I'll ask the patient, are you feeling any of this and make sure that we're adequately covered the area with the local injection. So I find that 20 works well, ten in pre-op, ten during the procedure. So once adequately anesthetized we'll start. So the incision is a transverse incision. So anytime you're placing a transverse incision across any limb you want to be very careful. You don't want to cut structures right. So you want to be very ginger in terms of your depth of your blade. So we're going very slowly. The structure most at risk with this approach here is the palmaris longus. And just below palmaris longus is going to be our median nerve. So we want to be very careful with that. So we don't want to be too aggressive. And we want to then bluntly dissect. So we're going to keep doing this until I see the palmaris longus tendon. Now, you should note that 10% of people don't have a palmaris longus tendon. So there are times where you'll do this and you will not find the palmaris longus tendon. And that's okay. But broadly, that's what we're going for. First is to find that palmaris longus tendon. And you'll notice I'm not cutting anything here because you can potentially come across branches of the palmar cutaneous nerve. So we want to be very ginger with that. Generally as I'm doing this I'm I'm talking to the patient as well. At this level, most patients don't have much discomfort. It's when you get a little bit deeper that they might notice. But I want you to notice at this point here is that we've got our antebrachial fascia exposed. If a palmaris is present, we'll place a ragnell on this side to retract that. So this goes that ragnell goes on the radial side to retract that. And then the skin hook is elevating distally. And what you'll see is a clean view of the antebrachial fascia, which is confluent with the transverse carpal ligament or the carpal tunnel ligament. All right. So once we're here, you can either a transversely cut the antebrachial fascia with a blade. Or in this case what I'm going to do is I'm just going to poke through gingerly with my tenotomy scissors. Like so. And you want to give this a good stretch because this can be a kind of a choke point, if you will. If it's not adequately released when we introduce the scope. And then we'll bring our double skin hook to elevate and grab the the distal part of the antebrachial fascia. So once we're through the antebrachial fascia I should be able to see the median nerve. So if you look here, that structure that's directly evident is actually the median nerve right here. So we're actually seeing the nerve right in our field immediately. And at this point, we can start to prepare the canal and introduce the nanoscope. At this point, I'll usually have my team open up the Arthrex system, which has two boxes, one has a nanoscope, one has the trocar and this dilator. And this side you'll see the synovial scraper. And this side here is the dilator. Okay. So we're going to first enter with the dilator. Now if you feel like it's a tight canal you can first enter with the freer. So just to show that we'll do that here. And I always put a finger at the distal end of the carpal tunnel so that I know what I'm aiming towards with my other hand. And sometimes there's some tissue here. So the freer sometimes is a little bit less traumatic. So we'll enter with that until I'm confident we can get in there easily which we can. So that was the freer. Now I'm going to enter with the dilator okay. So the dilator. Yep. There we go again. My fingers where we want to go. And we go slowly here because this is dilating the canal. This can be sensitive in patients. So I go slowly. I don't jam it in there. So I kind of nice and slow. We kind of come back a little bit just to kind of make sure it's nice and comfortable, and I always prepare the patient for the next minute or two. You're going to feel a lot of pressure because frankly, it only takes a minute or two to dilate and then to do the release from this point. But this is the point where they're going to feel the most. And so you want to prepare them for that. So again, you're going to feel a lot of pressure here. And like so once you're adequately in there then we'll go to the other side which is the scraper. And this helps to clear the undersurface of the transverse carpal ligament of any synovial tissue. So you have a nice clean look at the transverse carpal ligament. And we're looking for those transverse fibers once we enter the actual nanoscope. So here's our carpal tunnel release handpiece. So this is one of the instruments that we're going to be using to put together our release system. And this is the nano needle scope. And before we take off this rubber eyelet, we first calibrate it, which requires, once it's plugged into the console, simply pushing either button and it will calibrate the nano needle. You'll get a very clear green mark saying that it's been calibrated. Once that's done, you can take off the the cover. Once we take the eyelet off, we just introduce the nano needle into the handpiece and there's a little bit of play. You got to give it a little bit of a push. And then at the end it clicks in place. One of the things that's different about this than, say, a traditional scope is that this black part of the nanoscope right here is what controls your orientation of your screen. So oftentimes people will rotate their handle to get an up and down. But you want to actually make sure that this part here the nanoscope is centered and oriented parallel to the handpiece. Once we have that we're all inserted. Just taking a look at this, you'll see that there's a blade inside of the handpiece. And this lever here. When we push this, it deploys it, and you'll see how that blade deploys. When I let go of the lever, the blade retracts. So it's a nice system in that you'll only deploy the blade when you're actually pushing this lever. Otherwise the blade returns, and that creates a more safe cutting environment. The other thing is that this technique and this system use a retrograde cutting design, which I think is a safer way to cut. So you're always seeing what you're cutting, in contrast to the integrated cutting designs that are more of a push blade, where you're not seeing what you're cutting until it's cut. So let's introduce this. So now we've finished dilating, we've put together our nanoscope, and now we're introducing this in. And again we're going to follow the path that we created. It should go generally easily some of the times when it doesn't. The primary reason is that we haven't dilated enough, or the opening in the antebrachial fascia is too tight. So once we introduce the nanoscope and the carpal tunnel handpiece, one of the questions is often how deep to place this. So I'll generally place my finger at the distal end of the carpal tunnel as demonstrated here. There's also you'll notice that the handpiece is calibrated and you'll see numbers. You'll see a three and four showing here. Generally it's rarely passed to three and almost never passed to four. In terms of the depth. And that matters because if you're too deep, you could potentially injure the palmar arch. So placing both the finger distally and making sure you're okay from a depth perception is important. The other thing, as mentioned previously, is again, we want to make sure our camera orientation is right. So sometimes if the camera the nanoscope inside the handpiece is rotating, you might get a view like this. And then you may be tempted to rotate your nanoscope around to get a better view, and then it'll cause an obliquity with which you'll cut the ligament with the blade. So again, make sure that you're up and down with the nano needle in the handpiece as demonstrated here. Once you're satisfied and you know where you're at, you can deploy your blade. I generally recommend going a little bit at a time, a little bit of downward pressure again with that same digit that is identifying the distal end is helpful. If you'll notice here, you'll see that we're right where we need to be, because you'll see there's a clean line at the end of the ligament. And you'll see the transverse fibers that you're cutting as well. You obviously, most importantly want to make sure that there's no parallel structures that are in your field above you. The big thing that we always worry about is potentially the median nerve flipping up and being superficial to the handpiece and the blade. So you should only see these white transverse fibers coming across. And then you can deploy it as mentioned and start releasing. I'll do a little bit at a time where I'm deploying pulling back, and I'll drive the camera back in. And I want to see muscle and or fat pooching through and no transverse fibers when there's no transverse fibers and only muscle or fat pushing through. I know that we've released it. I do a little bit of time again. You'll see. Just muscle falling through. No transverse fibers. I'll deploy it one more time just to make sure. And you'll notice there's nothing there. And there's no feedback either relative to the blade as well. And before you exit, you want to make sure that your assistant has that skin hook on the skin. Because it is it is easy to cut the skin on the way out. So as long as you are retracting that skin with that double skin hook, you should be safe and exit and finish your release like so. At this point, you're done with your endoscopic release. Once the endoscope is out, it's still important to take a look inside and make sure that you can see the two leaflets have been released. I'll often move the retractor more superficially so as to see the antebrachial fascia a little bit better and make sure that I'm adequately released distally. If there's any residual transverse fibers at this point, you can obviously release them as well. Once satisfied, we'll take this double skin hook and we'll switch the position to this side. And then we're going to release the antebrachial fascia proximally. So you'll see the antebrachial fascia right here. I'm not going to do a slide I'm going to first make sure that I have enough dissection proximally to make sure that I'm in a safe place. And then I will go ahead and release the transverse fibers. I'm always raising my hand as I do this, and you'll see that the antebrachial fascia, approximately has been released as well, at least a centimeter or two. And here you can see the median nerve directly released, uninjured and directly in your view. Once satisfied with the release, I wash and close in standard fashion. Nothing too fancy. I typically use a dissolvable suture. In this case, we're using a prolene suture to close. Simple. Put a light dressing on and then send the patient on their way. My post-op instructions include keeping the dressing on for a couple of days. After a couple of days of dressing can be removed, they can shower, wash normally, everything can get wet and I use a dissolvable suture which the regular bathing helps to dissolve away. I typically don't require any therapy unless there's an issue, and I let them wean back to their activities as tolerated. I always advise that to take it slow the first couple of weeks, some amount of swelling or soreness can linger for about 2 to 6 weeks, but again, mostly common sense restrictions. A few tips and tricks to keep in mind when you're starting this out, particularly if you're doing this in the office setting. Doing this without a tourniquet can be challenging, and I think it's reasonable to use a tourniquet until you're comfortable with the technique and the visualization. It's a much bloodier field when you're not using a tourniquet, and tourniquets can be uncomfortable for the patient. A couple other things to keep in mind in terms of tips and tricks is avoiding sliding proximally. So that last part, you might have noticed that I released the antebrachial fascia. It's tempting to just slide your tenotomy proximally, but the median nerve is very superficial at that level, so elevating, visualizing, and then releasing that antebrachial fascia proximally is a safer way to go. The other thing I would tell you in terms of doing these cases awake, is that sometimes people have varying responses to the local anesthetic, and if I feel like they're not getting a good response to the lidocaine, I'll then use a different agent, like a marcaine, and sometimes a different class of local anesthetic additively can help make a difference as well. There's a number of really unique advantages to the arthrex and nano endoscopic carpal tunnel release system. We've touched on a few of them, but just in summary, one is the simplicity of the set and the design. Two simple boxes the nano needle inserts into the handpiece. It has a clear cannula which increases your visualization of your field during the release. You've got a sharp retrograde cutting blade, which is a safer cutting style, and it keeps and allows you maximal control. But perhaps the most significant aspect of this is the fact that this system is not reliant on using a traditional scope tower. So this allows you to do these procedures anywhere. It could be in the hospital, it can be in an ASC, but also it can now be done in your office because all you need is a console and you are no longer are required to have a large scope tower and its associated heavy equipment in order to do an endoscopic carpal tunnel release.

Wide-Awake Endoscopic Carpal Tunnel Release Using the NanoScopic™ Release Disposable System

Erik Kubiak, MD (Las Vegas, NV), delivers a modern take on cerclage fracture management. He addresses the common challenges with traditional cerclage cables and the evolution of nonmetallic techniques. Part of this evolution is the development of radiopaque FiberTape® cerclage, and Dr. Kubiak presents cases highlighting the use and benefits of this technology.

Cardiothoracic Surgery

Shoulder

A Modern Take on Cerclage With Radiopaque FiberTape® Cerclage

Kubiak from Las Vegas, Nevada. Here to give a modern take on cerclage technique. Cerclage cables in any application of trauma have always sort of carried the concerns about breakage of implants. Issues with fracture security, metal fretting, potential vascular injury as a result of these sharp metal fragments injuring vessels and the proximity, and then particularly in the proximal femur. Third body where where you have little bits of metal from the broken cerclage cables involving themselves or wandering into the articular surface of the hip. Classically, these techniques are used like this to secure the femur, particularly in periprosthetic settings or in implant revision settings. We've sort of struggled with the metal implants and have evolved over the last 20 years to using polymer implants. The first of these was a nylon polymer implant with a polyethylene core. We've really moved away from that implant to a uhmwpe fiber tape implant. Issues with that fiber tape implant on initial presentation, where not everyone was comfortable with an implant they could not see radiographically. Henceforth, the development of a bismuth trioxide impregnated uhmwpe implant, which is radiopaque and leaves evidence of the surgeons activity on radiographs. Postoperatively. Issues with fracture security as demonstrated by the old metal implants. An evolution of that technique to a oraf dominant fixation construct, where the cerclage cables are used for provisional fixation, which is kind of where we've gone. And again, issues with potential metal dissimilarity. The cerclage cable versus the plate, and again, not free of the risks of breakage. And the third body migration into the articular surface. This is the bismuth impregnated uhmwpe material recognizable by its yellow color. And in this circumstance used to reconstruct after a clamshell osteotomy for a Vancouver B periprosthetic femur fracture complex. Periarticular trochanteric femur fracture. Not really amenable to oraf. Raf going to be treated with a total joint arthroplasty. This is the case where we used the cerclage cables to reconstruct the femur around an implant. And as evidenced on these fluoro images, you can see the radiopaque cerclage material quite readily on multiple views of this femur. And then this person, due to some GI distress, ended up with a CT scan almost three months later. And you can see that the cerclage cables are readily apparent on the CT scan as well. Another case 78 year old female poor bone quality sick patient. Pre-existing hip osteoarthritis, which necessitated a total hip arthroplasty. You can see here as circled the presence of the radiopaque cerclage cable fiber tape around the proximal femur. And then on the post-op films on the post-op plain films, again, the readily apparent cerclage cable fiber tape in its location were placed still secure at three months. More and more frequently, we see periprosthetic fracture around the proximal humerus. This is often a almost a more difficult situation than the femur because the bone quality is so poor. We're working to find improved fixation techniques to maintain stability of these fractures and allow patients to regain function in their arm and try to restore bone stock. And these circumstances were now sort of evolved to using allograft bone struts with multiple cerclage tapes for fixation allograft strut prepared with grooves to maintain the position of the cerclage cables when passed, and then application of those as seen in these fluoro images you can see there, they're readily apparent radiopaque fiber tapes or collage around the implant, both in the fluoro and in the post-op period, as evidenced here in these plain films. The evolution of this suture material going from a fiber tape cerclage to a fiber spacer collage with its now radiopaque, it results in the same strong fixation readily visible on fluoro radiographs and CT. It has the advantage of being retention able with little to no concern of third body wear, and it's easy on the bone. We don't see the subsurface resorption that we did with the nylon polymer constructs. Thank you.

A Modern Take on Cerclage With Radiopaque FiberTape® Cerclage

Expanding on the trusted Syndesmosis TightRope® platform, the Syndesmosis TightRope PRO implant is the next generation in syndesmotic fixation. Updated instrumentation and lower-profile implants provide efficiency by design, enabling effective treatment of syndesmotic injuries.

Experience the Syndesmosis TightRope® PRO Difference

Experience the Syndesmosis TightRope® PRO Difference

ApolloRF® H50 Probe

At the Orthopedic Trauma Fellowship Forum, Jack W. Weick, MD (Columbus, OH), presents an overview of the indications, operative setup, and surgical approaches for scapular fixation.

Trauma Upper Extremities

Scapular Fixation for Scapula Fractures

OrthoPedia: Scapular Fixation for Scapula Fractures

Michael A. Gallizzi, MD (Vail, CO), discusses a salvage medial branch transection (MBT) procedure as a definitive solution for a 36-year-old female with right-sided low-back pain after two previous rounds of radiofrequency ablation provided only temporary relief.

MBT as a Definitive Solution After Temporary Relief From Radiofrequency Ablation

As a medial branch. Transection procedure continues to grow in popularity. More and more patients are going to present to your office that have had previous radiofrequency ablation. That may not have lasted very long for them. So essentially, a lot of these patients will continue to have repetitive rfas, and their effectiveness continues to get shorter and shorter over time. But they still were effective for the time that they had the ablation. What a salvage medial branch transection can do is bring that effectiveness back to them as a definitive procedure for their back pain. Today, we're looking at a 36 year old female soccer player who had continuous right sided low back pain. She had two previous rounds of radiofrequency ablation. Unfortunately, the radiofrequency ablation on both of those rounds lasted less than three months, but it did hit the spot. Typically, these patients have had some success with the radiofrequency ablations. The pain relief just doesn't last. And for these patients, a salvage medial branch transection is a great option as a definitive procedure for their back pain. One thing to check radiographically with these patients is to make sure that they don't have any instability on flexion, extension, x rays, or any other contraindication that would tell us a medial branch transection shouldn't be performed for this patient. What I look for is patients that have a stable spine, with no evidence of slipping more than two millimeters on flexion extension x rays. The diagnosis for these patients has typically already been proven with successful medial branch blocks and or radiofrequency ablations that have treated that area, but the ablation has just not lasted. Many times, these patients have had multiple rfas over years and months, and they just keep going back for this short lived treatment. The revision medial branch transection is a great salvage procedure to be able to make that feeling of pain relief permanent. When I'm performing the treatment for a medial branch Transection revision. What I want to make sure you understand is how much scar tissue is going to be present from the previous radiofrequency ablations. The ablations have essentially caused a huge scar ball to form by that thermal injury to all the surrounding tissue. So really identifying the floor of the transverse process and moving out laterally to the accessory process as your lateral extent. Now what you're going to do is move both cranial and caudal on that transverse process to be able to start peeling back all that scar tissue. What you really want to avoid is going lateral to the accessory process, because in that area you're going to start getting the lateral branch that innervates the deep paraspinal musculature. You also want to avoid going to cranial or caudal, as we don't want to enter the neuro foramen, where the exiting nerve roots are coming out, as that can cause a neurologic injury. So being very careful on palpating and always making sure you're on bone is very important to a revision. Medial branch transection. Once your exposure is complete and you can adequately visualize the landmarks that we just discussed, what you really want to do is find that medial branch coursing out of the cranial neural foramen, down in between the accessory process and the lateral aspect of the facet joint. What you want to do next is find that branch, transect it with either punch or scissors to be able to completely renovate the medial branch, and then once that is complete, you take your high frequency RF probe and essentially denude all the neural tissue from the lateral facet wall all the way to the accessory process. This patient had an excellent clinical outcome since the two week post-operative period. They have been pain free, and she was able to return to all her mountain athletic activities without any recurrence in her pain. Postoperatively. What we do is we do put in some nylon sutures that we leave in for about two weeks. Well during that time period, we let them get back to their ADLs and walking, but really don't let them push any athletic activity. Once the sutures out and the skin has completely healed, we begin a scar massage routine in physical therapy to be able to get the soft tissue planes to slide. And then we get them into sports specific physical therapy as needed, to help them optimize whatever sport they want to get back to. Being able to offer your patients a salvage for a previous successful RFA that just isn't lasting, allows them to get back to their activities in less than two weeks. Really gives a motion preservation procedure that allows them to continue to avoid any talk of fusion. This is a low risk, high reward offering in the setting of a failed previous RFA and allows immediate return to sport and improvement of their spinal pain and low back pain without any talk of a spinal fusion.

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