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NanoNeedle™ Scope 2.0
Gains National Spotlight Through

Star MLB
Pitcher's Recovery

This animation provides an overview of the features and benefits of the Knotless 1.8 FiberTak® soft anchor for the treatment of shoulder instability.

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Knotless 1.8 FiberTak® Soft Anchor for Shoulder Instability Repair

Knotless 1.8 FiberTak® Soft Anchor for Shoulder Instability Repair

John Ogunlade, DO (St. Louis, MO), demonstrates the technique for decompressing the lateral recess through an interlaminar endoscopic approach.

Endoscopic Approach to Lateral Recess Decompression

Speaker  Hi, my name is John Ogunlade. I'm an endoscopic spine surgeon. Today I'll be presenting on lateral recess decompression. So first you want to chew AP through the intended surgical level. So we're going to be targeting L405. What you can see here, this is the interlaminar window of L405. And then we're going to mark this inferior medial edge of that lamina of the L4 level. And that looks pretty good. We're right at the midpoint of that inferior medial edge of the lamina. And that's where we'll make our incision. So we'll make an incision through the fascia. And then we'll go straight in following the angle of our c-arm until we find a positive stop. And that's a positive stop there. You can actually see that I'm scraping the bottom edge of that inferior laminar edge there. And that looks great. So that one step dilator is on the inferior edge of that lamina. And then we'll use a tubular retractor to dilate over that one step dilator. And I like to have the bevel facing cranially. So that way when we come in, the first thing that we see is that area we're targeting the bony surface. And then now we can bring in our scope. So now that we've brought in our working tubular retractor, we're going to introduce our radio frequency flex tip probe to identify the area that we just targeted. So for orientation purposes, you can see that the bevel of my cane is facing cranially. Speaker  So this is towards the head. This is towards the feet. We are here. This is lateral and this is medial. So now that we brought in our tubular retractor, we're going to now expose that inferomedial edge of that L4 lamina. And this is kind of exposing what we were targeting so that we can start our lateral recess decompression. You can see this little slope here kind of signifies where that medial edge of the lamina falls off. There's a little bit of fibers from the facet capsule. And we're ready to start our drilling. So we're going to introduce this drill. This is a little bit more aggressive. And really we want to drill along this attachment of this ligamentum flavum where it attaches to the ventral surface of this lamina. So you can see this is part of this defect that I just created using the drill. And you can see this is actually the ventral surface of the lamina where we're going to focus our drilling. And we're going to follow this nice curvilinear path along the inferior edge of the lamina so that we can detach the ligamentum flavum. We've seen how you can use the fluted burr for more aggressive resection of the medial border of the medial facet joint. I'm going to now demonstrate how you can use a diamond burr to really target and remove some of this attachment of the ligamentum flavum. Speaker  But really what I want to demonstrate here is how we're using this diamond burr push directly on this ligamentum flavum and drill right along the attachment of the ligamentum flavum. And that's how we're going to detach our ligament and do our lateral recess decompression. Often we'll run into the most cranial extent of our interlaminar window and we may have to extend that. So what I'm going to do is I'm going to use this diamond burr to polish off some of this soft tissue. Then we're going to also extend our interlaminar window more cranially so we can reach the insertion of the ligamentum flavum. So what you might see here is by just gentle pressure on any soft tissue, you could use that to polish and remove that soft tissue attachment from bony surfaces, so that you don't have to go back to using a pituitary or any other instruments to increase your field of vision. So we're going to deploy our sheath here. And we're going to go more cranial to remove some of this laminar edge. So we can continue our detachment of that ligamentum flavum. And the goal here is to work in planes. So once you have reached the depth that you want for your detachment, the ligamentum flavum, you're going to keep that depth and you're going to follow this curvilinear path all the way caudally so that you get nice smooth lines. Speaker  So before we get to the cranial attachment of our ligamentum flavum for our lateral recess decompression, it's important to find the inferior border of this caudal attachment and expose it. This is a little bit of synovium here. We're just going to move that out of the way. What we'll do is we'll use the drill to detach the Ligamentum flavum both Cranially and Caudally. And I can feel a bone deep to this soft tissue. It would be great to expose this so that when you go for your caudal ligamentum flavum detachment, you can actually see the removal and the detachment of that caudal ligamentum flavum. So again we're on the patient's left side. This is now the top of the L5 lamina right where it becomes the spinous process. And what you can see here this is the inferior articulating process of L4 on the left that's coming to create the joint with the SAP, which is going to be right underneath this soft tissue. And what we want to do is we want to trim this ligamentum flavum off of the ventral attachment of this L5 lamina. So that's going to be part of our goal. And we'll use the shaver to do that. Right now our orientation the top of the screen is directly cranial. Speaker  So this is towards the head. This is towards the feet. This is lateral and this is medial. And what you're noticing is that I'm constantly changing the rotation of the scope by adjusting my hand so that I can get the best view without destroying tissue. That's unnecessary. So this is the medial border of our inferior articulating process of L4. That's our ligamentum flavum attachment to that inferomedial articular process of L4. And now you can see we're now attaching the ligamentum flavum from the ventral surface of the L5 lamina. So you can see here this is the cranial edge of L5 and the ligamentum flavum attaching to the ventral surface of it. We're going to detach that using this diamond burr. And again you know there's different shaver burr tips that you can use whether it's fluted or diamond burr. I would argue that you should use a diamond burr for this step, as the attachment of the ligamentum flavum will come up very quickly. Okay, so what we're looking at now is the facet joint. This. Here to the left is our inferior trickling process of L4. And this here is our superior articulating process of L5 coming up from the lamina of L5. We're going to drill along this attachment of this ligamentum flavum. And for the goal of this surgery for decompressing the lateral recess, we really need to get to the superior articular process as that's our compressive lesion. Speaker  If the patient has significant amount of ligamentum flavum hypertrophy by detaching it from the superior articular process, you're also decompressing the neural elements. So now we can start to detach our ligamentum flavum. You're starting to see the ligamentum flavum thin out to this thin wispy white insertion point. So we know that we've detached it caudally. We can now follow this out laterally, and it's very hard to get the lateral attachment of the ligamentum flavum completely because it goes out the foramen. However, you can use this as a guide of detachment from the actual superior articulating process of L5 in this case. And from there we'll make our turn cranially so that we can detach the flavum off the ventral surface of L4 and go all the way to our cranial attachment. So now we're drilling along the medial ventral surface of L4 along the IAP to the lamina. So occasionally I would encourage you to take a break so that you can actually clean up some of these surfaces and remove some of the soft tissue that may impede your view, as in this case, some of the soft tissue creep was getting in our way. And I want you guys to see the attachment of the ligamentum flavum. So now we're here along the medial border of the facet joint. And we're going to continue to remove this ligamentum flavum from its medial attachment. Speaker  We can follow this all the way up cranially and caudally so that we're making one smooth line across the switch that joint. And now we're getting to the attachment of the ligamentum flavum. So now you can clearly see the attachment of the ligamentum flavum ventrally at the caudal aspect of the L4 lamina. And as we continue to work with our drill, we're going to detach it completely. And then we'll use our Kerrison to remove the ligamentum flavum on this ipsilateral side. So we're detaching the ligamentum flavum from its cranial L4 attachment. So it looks like the ligamentum flavum is ready to be detached. We can continue using the drill. Or we can use this angled curette to now detach the ligamentum flavum. We're going to use this Curette to go circumferentially around the ipsilateral medial facet joint and come all the way down to the lamina of L5. So now that we've detached the ligamentum flavum, both cranially and caudally, we'll use the kerosene to detach ligamentum flavum. You can see this. Here is the sap here. We'll decompress that as well. We're going to grab the ligamentum flavum, and we're going to peel it off from caudal to cranial. So you can see our neural elements and our thecal sac down below. This is our sap here. And now we can actually take down some of this sap. Speaker  Now we're just going to remove the bulk of this ligamentum flavum. It's still attached medially. So it may be hard to get out, but you can typically detach it in one big piece. So we've successfully detached the Ligamentum flavum, both Cranially and Caudally. Now we're just going to remove this ligamentum flavum with the pituitary. So you can see we have our dura exposed. There's still some flavum here. Medially. We can use a kerosene to detach that. But you know I'm going to use the shaver. We're going to go a little bit more lateral with our lateral recess decompression so that we can get to the lateral edge of that exiting route. So. This is now our AP. You can see that we've now completely decompressed this traversing route. It's the last of our ligamentum flavum still attached here as it starts to go out the foramen. Oftentimes you might find that the facet joint is significantly overgrown. And as in this case, you would want to make sure we have a thorough decompression until we reach the edge of that lateral recess and the traversing root. So that would require us to remove a little bit more of this medial facet joint. So if you don't get to this edge of the sap, you may have an insufficient decompression. So don't be afraid to go back, bring in your shaver and safely remove the medial border of overgrown facet joint so that you can reach the lateral edge of this traversing root to ensure that it's decompressed. Speaker  And now we use this soft tissue shaver to clean up some of these floaters. So now that we've done our lateral recess decompression we'll take a look at the anatomy. So right now we're resting on the superior edge of the L5 lamina. You can see our laminectomy defect where we have detached the ligamentum flavum from the ventral surface of the lamina. Here is the superior surface of the L5 lamina that we've detached the ligamentum flavum. You can follow this lamina up to the sap. You can see that this is now the lateral recess. And this is our traversing root completely decompressed with our disc space underneath. We continue in this orientation here. We'll go out the foramen. And again, the goal of our lateral recess decompression is to make sure that this traversing root is completely decompressed from the inferior border of that disc space to the superior border of that disc space. You can see it's completely mobilized, and that's our disc underneath. So if you look at the pre-op image and compare it to the post-op image, you can see that our interlaminar window has been widened and that the lateral recess and the facet joint has been trimmed very minimally to decompress that traversing root.

Endoscopic Approach to Lateral Recess Decompression

Benjamin G. Domb, MD (Chicago, IL), demonstrates a hip capsular closure using the SutureCast™ suture passer and LoopLoc™ knotless implant. Dr. Domb provides surgical pearls for suture management and tensioning of the LoopLoc implant to complete the closure.&nbsp;

Hip Capsular Closure Using the SutureCast™ Suture Passer and LoopLoc™ Knotless Implant 

Speaker  My name is Benjamin Dome. I'm the medical director at the American Hip Institute. And today we will be demonstrating capsular closure in the hip using the suture cast passing device and the loop lock capsular closure device. The suture cast can load and expel up to 40mm of suture under the capsule. In order to load it, we switch the switch forward and then put the suture into the jaws, and we put it all the way into the apex of the jaws beneath the teeth. And then we load the suture like so. And again, if we fully retract the button, then that pulls in up to 40mm of suture. Once we've passed through the capsule, we can similarly eject that 40mm of suture like so. In order to pass the suture through the other side of the capsule, we pass the suture cast through the other side of the capsule, extend the jaws, and then use the teeth on the jaws to grasp the suture. So we want to grasp the suture very close to the apex of the jaws, and then retract like so, and pull it through the other side of the capsule. So here we're going to load the end of the fibre link from the loop lock into the suture cast. So we place it like so into the apex of the jaws, and then retract this all the way again. It can retract up to 40mm. We will then come in through the mid anterior portal. Speaker  We're going to grab the capsule just beneath the rectus femoris. So this is the indirect head of the rectus femoris here. And this here is capsule. We grab capsule just beneath the rectus femoris. And this is on the acetabular side. So we penetrate through the capsule here. And then we can inject our suture like so. And then we'll come out with the suture cast. I'm going to come in through the distal anterolateral accessory portal, which gives me a good angle to grab the capsule on the femoral side. We'll come in through the capsule on the femoral side here. And we'll use the jaws to grasp this suture. Like so. And then we pull the suture all the way through. At this point I'm going to bring both sutures into the same cannula. That. My assistant will hold on to the loop lock like so pinching the white tab against the black card. And we're going to pull through the capsule. Hold the scope please, Until we see the end of the loop block here. And at this point we'll cut. So I'll cut the fiber link. So now we take the suture off of the tab one. And we're going to pull out the suture from tab two. And we want this suture to come all the way out of the card out of tab two. And then we pass the end of this suture through the loop. Of the loop block. Speaker  And then we pass it through the wire loop attached to the white tab. And at this point we pull through using the white tab. And now we are about done with the card. And we have these two ends which we need to even up. So we're going to pull tension on that suture until our ends become even. So now with our ends close to even, we put our finger in the middle here and pull on the middle so that we have even everything up. So a pearl to minimize the friction as the loop lock is tightened, is to place a retriever into the joint and to grab the loop on both sides. So we grab the loop here and we grab the loop here. And in this way we are actually setting up a construct where the Friction will be against the retriever rather than the sutures having friction against one another. So we can lock the retriever there and then proceed with tensioning. Tensioning can be performed one suture at a time, or it can be performed with both sutures at the same time. And I'll demonstrate the latter. So let's just hold like that, please. The retriever, our assistant will hold the retriever. And I'm going to tension both sutures at the same time here bringing the mechanism down into the joint. And then when we are near, we will release the suture retriever and take it out and complete the tensioning of our loop lock. Speaker  And that completes the capsular closure in this location. We can now use a closed ended cutter to cut the remaining suture. And the closed ended cutter will pass down right on to the loop block device. So here's another view showing that capsular closure right beneath the indirect head of the rectus femoris, which has been preserved in its entirety. We'll now move on and do a second loop block for demonstration purposes. And it's interesting to note that one option is to put the first loop block in and not tension it entirely. Then pass the second loop block and then tension both sequentially. In this case, for demonstration purposes, we've tightened the first one entirely and we'll now place the second. As I open the suture cast device, note that the jaws actually open side to side in a horizontal fashion rather than vertically. Again, we'll pass the end of the suture from the fiberlink into the jaws. There. The horizontal opening makes it easier to catch the suture without catching capsule. So here we're going to come again through the acetabular side of the capsule and take our bite. And coming inside the joint. We can view as we expel the suture. And then we will come through the femoral side of the capsule. Here. Take our bite. Extend our jaws. And grab our suture and then pull it through. Hold the scope, please. As before, we pass this fiberlink all the way through. Speaker  The capsule until we see the loop lock. We'll cut the fiber link here and now. We will take off tab number two. Take the end of the suture. Pass it through the loop lock, then pass it through that nitinol wire attached to the white tab and then pull the white tab through. That. At this point, we detach from the card. And we even up our ends. So when the ends are all the way, even then we can put a finger in the middle of the loop and make sure we have pulled all the slack out of the loop. And at this point, I'm going to tension this by tensioning both at the same time. And we'll see that that slides the loop lock device all the way down to complete the fixation. And at the end we can do a little bit of tensioning of one and tensioning of the other, cut our ends and. When we pass the closed cutter down, we can actually use it as a pusher and apply some additional tension before we cut. And that completes our repair of this capsule using two loop lock devices. This accomplishes two limbs of suture around the capsule in each of the leaflets. We have an excellent closure, low profile knotless devices. So we do not have not stacks, which can potentially be a place where scar tissue can occur. And we get excellent closure with very high strength and security.

Hip Capsular Closure Using the SutureCast™ Suture Passer and LoopLoc™ Knotless Implant&nbsp;

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

At the Advanced Shoulder Arthroscopy: The Cowboy Way course, Kevin W. Farmer, MD (Gainesville, FL), reviews the evolving role of reverse shoulder arthroplasty for rotator cuff tear arthropathy, emphasizing that glenoid lateralization, inferior glenosphere positioning, and optimized implant design are key factors in improving pain relief, range of motion, and functional outcomes across both older and selected younger patients.

Hidden

Reverse Total Shoulder Arthroplasty for Massive Rotator Cuff Tears: When and How?

OrthoPedia: Reverse Total Shoulder Arthroplasty for Massive Rotator Cuff Tears: When and How?

The Arthrex ElbowLOC® positioner is a modular, upper extremity positioner that gives the surgeon the choice of supine, lateral, or supine-suspended positioning for elbow surgery, as well as a wrist traction device for wrist and hand arthroscopy. The ElbowLOC positioner is easy to use and set up, and housed in a space-saving single autoclavable tray.

The Arthrex ElbowLOC® Elbow and Wrist Positioner

The Arthrex ElbowLOC® Elbow and Wrist Positioner

James McWilliam, MD, (White Plains, NY), demonstrates the correction of a type III tailor’s bunion, characterized by a widened 4th-5th intermetatarsal angle, using a more proximal osteotomy on the 5th metatarsal, access at the 5th metatarsal styloid, and fixation with a bevel screw. This approach allows for a greater reduction of the intermetatarsal angle while providing a large surface area for fixation.

Minimally Invasive Correction of a Type 3 Tailor’s Bunion Using a Beveled Screw

Hello, I'm Jim McWilliam from White Plains, New York, and I'm going to talk about minimally invasive surgery on the foot with regards to bunion deformity. So if there's a large intermetatarsal four five angle or if there's significant lateral bowing of the fifth metatarsal, you might want to perform your correction via a more proximal osteotomy. And I'll show you how that's done. And I'll show you an alternative fixation method. Now here we've marked the trajectory of the fifth metatarsal in both the lateral plane and the AP plane. And I'm going to use that sort of as a rough guide for where I'm going to do my fixation. So this is going to be the trajectory of my screw. You can see that instead of being in the high and inside position of a traditional Jones screw, it's going to be going right through the fifth metatarsal Styloid. And I'm going to make my osteotomy where the wire crosses the medial cortex of the fifth metatarsal. So my osteotomy is going to be roughly here more proximal. I might even shift it a little more proximal in that x ray that. So right about there, before the watershed zone of a zone three proximal fifth metatarsal. But we're going to be proximal enough that we're going to get a good level of correction. All right. So we're going to make our incision. I will typically make the incision directly lateral. And that will kind of allow me to do a long oblique osteotomy. I'll use my little elevator. Remember this has the ideal curve to minimally elevate the periosteum dorsally and planoly. To kind of minimize soft tissue disruption but allow enough exposure. All right. So once again I'm going to go straight across just like I have with the other osteotomy. All right. X ray. So I've gone across the I've gone across the entirety of the bone. Now remember there's a declination of the fifth metatarsal. So if I just rotate my hand approximately, I'm going to be cutting distally. And the dorsal cortex. Then I've gone through there. Now, similarly, if I rotate my hand approximately and maybe direct it down just a little bit, I'm going to be cutting approximately. And the planter cortex, you can see I've got my shift there. So this guidewire is a little bit easier to work with. It's the 1.6mm guidewire for the four millimeter beveled screw. And because it's 1.6mm, it's going to be a lot easier to get my direction that I want. So I'm literally starting at the fifth metatarsal Styloid. And I'm going to drive it into the osteotomy line, kind of ideally hugging that medial cortex when I get to the osteotomy. And then we'll check on the lateral and make sure we're in the appropriate orientation there as well. We're pretty good there. So now it's simply going to be a function of moving the metatarsal over and driving the guidewire across the osteotomy and an intramedullary position. So I've got my metatarsal shifted. I've got my guidewire in the right position. So now we're just going to drive the guidewire across. You see how just putting the guidewire in this trajectory across the osteotomy site actually forces the fifth metatarsal medially, affecting your correction. So we've got good correction. We've got good position of the wire in this plane. Let's check the lateral. We've got good correction. You can see I actually cracked the dorsal cortex a little bit with my osteotomy. But we should get good adequate fixation distally without any problem. So now I'm going to use this wire as a guide for my incision. And it just minimizes trauma to the skin and it enhances cosmesis. So I'm going to take the back end of the blade and just push it down. This is an 11 blade. I'm just going to push it down along the guidewire to the fifth metatarsal. So I'm good there. Now we'll take our measuring device. It's beveled to allow us to more closely measure the appropriate depth. We're going to check that the bevel is facing in the right direction. And everything's lined up well. And we still have maintained our medial shift of the distal metatarsal. I'm going to drive this wire out the tip because not only is it our guide for the screw, but it's our provisional fixation and it's just not worth having to do everything over again. We're going to drill over this under fluoro. Not necessarily wanting to go through the medial cortex. All right. We're pretty good there. So if we line up the laser line on the drill with the laser line on the screw, we know what side the bevel is going to be on. Once the screw is buried in the soft tissue, it's just a little visual guide. It only works as long as you keep the driver engaged on the screw. So once the driver is no longer engaged, you're going to have to do it with fluoro. So there's our final fixation our final correction in the AP plane. And there's the lateral.

Minimally Invasive Correction of a Type 3 Tailor’s Bunion Using a Beveled Screw

Sanj Kakar, MD (Rochester, MN), demonstrates how the NanoNeedle™ scope allows for better visualization to assess the scapholunate joint during wrist arthroscopy procedures.

SpeedPearl: Assessing the Scapholunate Joint for Stability With Nano Arthroscopy

Speaker  When performing wrist arthroscopy for suspected scapholunate ligament injury. I like to use a nanoneedle scope because it's small, it's flexible, it's lightweight, and it allows easy navigation through a tight midcarpal joint. Since the scaphoid tends to flex and pronate when the scapholunate ligament is injured, I typically create the ulnar midcarpal portal first and then the radial Midcarpal portal. I then use a probe to examine the cartilage, the location of the scapholunate ligament injury, its reducibility, and also the insertion of the dorsal intercarpal ligament, which is another critical stabilizer of the carpus.

SpeedPearl: Assessing the Scapholunate Joint for Stability With Nano Arthroscopy

The hip-length DiamondCut™ burrs feature a diamond-coated head optimized for precise control during resection of pincer and cam deformities associated with femoroacetabular impingement (FAI) surgery.

Hip DiamondCut™ Burr

Hip DiamondCut™ Burr

Andrew L. Clavenna, MD (Dallas, TX), demonstrates how to use the Arthrex Graft Gun for MIS spine fusions, walking through assembly, loading, and the device’s key features and benefits.

Arthrex Graft Gun: Surgical Technique Demonstration for MIS Spine Fusion

Speaker  Hello, I'm Doctor Andrew Clevinger from Dallas, Texas. Today I want to demonstrate how I incorporate the Arthrex Graf gun along with Graf Net XL into my minimally invasive fusions. The Graf gun system includes a reusable instrument set and a disposable kit. The disposable kit features a cannula and flexible barbed plunger designed to evenly advance the graft material. The cannula is bayonetted and clear for direct visualization during delivery and includes a oval seven millimeter by ten millimeter Radiopaque tip for Fluoroscopic confirmation so you can ensure your position is in the disc space. Each cannula holds approximately six CCS of graft and is long enough to accommodate even the deepest decompression tubes. The reusable components are the primary housing front and back assemblies, shield protector and cannula. Loader's assembly is simple thread the front and back assemblies into the housing. These are clearly marked one and two for easy identification. Finally, snap the shield protector into place. This shield ensures the disposable plunger remains within the sterile field. To load the cannula, use a sledge provided in the tray. Pack with a small amount of graft into the sled and compress it with your thumb as you insert it. Don't overfill the sled. Less is more. This technique helps minimize graft loss and speeds up the loading process. And you repeat. Using your thumb again to hold the graft down. So we'll repeat this until we get the volume of graft we need loaded. Once the cannula is loaded, attach it to the graft gun and insert the plunger. The plunger has an arrow indicating the correct orientation. Advance the plunger until the graft is just at the radiopaque tip. Ready for delivery. At this stage of the case, you've completed your Diskectomy and are ready to fill the disc space. We've added Contrast Agent to the graft for better fluoroscopic visualization. Under fluoro you can see the cannula tip and the graft material. Here you can see as I advance the plunger, the graft is delivered precisely into the intervertebral space. The Arthrex graft gun provides excellent control, visibility and efficiency, eliminating the need for mallet impaction and reducing surgical time compared to traditional funnels.

Arthrex Graft Gun: Surgical Technique Demonstration for MIS Spine Fusion

Designed to provide anatomic contour with precise instrumentation, the Arthrex Proximal Tibial Plating System features 4 unique plate styles, equipped with advanced variable-angle locking capabilities and KreuLock™ locking compression screws, to optimize treatment of proximal tibial fractures.

Arthrex Variable-Angle Proximal Tibial Plating System

Arthrex Variable-Angle Proximal Tibial Plating System

Patrick A. Smith, MD (Naples, FL), presents an analysis of current literature showing the outcomes of rotator cuff augmentation with dermal allograft.

Rotator Cuff Tears: Literature Review of the RoHI Score and Augmentation Decision Making

OrthoPedia: Rotator Cuff Tears: Literature Review of the RoHI Score and Augmentation Decision Making

Daryl C. Osbahr, MD (Orlando, FL), reviews the contents and use of the Onlay MPFL Implant System with Knee FiberTak® anchors for patellar fixation and the FastThread™ interference screw for femoral fixation.

MPFL Reconstruction Using the Onlay MPFL Implant System With the FastThread™ Interference Screw

Hi, I'm doctor Daryl Osbahr. I'm with Rothman Orthopedics of Florida at AdventHealth. Today we're going to be talking about the knee. Fiber tech only Mpfl kit with the fast thread screw. So I'm going to explain to you what's in the kit. We're going to use the hybrid knee fiber tech with the one knotless tensioned loop and sliding suture tape with needles. We also have a new and exciting patella ratcheting knee fiber tech guide, and we have the 2.8 hard bone drill you can see here on the table. We also have the sutures that we're going to be able to put through the graft. We have the disposable fast thread screwdriver. We also have the drill bit and we have the seven millimeter reamer. We have the guide wire. And then we also have the two fiber standards to be able to pass the graft. In addition we have the Mpfl template as well as the disposable graft board for graft sizing to give orientation. This is the medial side of the knee and the lateral side of the knee. So some of our landmarks this is the patella that I've outlined. This is the medial epicondyle that I've outlined. So this will give us our access to the patella side of our fixation in the femoral side of our fixation. I'm going to make the patella incision first at the medial aspect of the patella. To give orientation this is the medial side of the patella. We can see some of the mpfl tissue and retinacular tissue coming in. And we can see the vastus medialis obliquus coming in to enter the attachment site. For the medial side of the patella. There are several goals of what we can establish here. If we're considering doing a VMO advancement, we can make our medial parapatellar arthrotomy slightly extending up into the vastus medialis obliquus to be able to advance that medially. If not, we can do a standard peripatellar arthrotomy on the medial side. Here you can see I'm keeping the vastus medialis obliquus intact and not actually advancing it. In this case, once I have the medial side of the patella exposed, I will use a combination of a curette and a rongeur to prepare a good bony surface here, so our reconstruction can heal against this surface. Staying extra articular and along the mpfl. We can see this interval that we're able to develop to be able to get right down to the femoral side. Now I'm going to mark the superior medial border of the patella, as well as the midpoint on the medial aspect of the patella. These are our two fixation points for our knotless technology on the patella side. Now I'm going to show you the patella ratcheting guide. We can see the button right here which you can push down and allows you to telescope. So that way when we get this fixated to the patella, we have a better grasp to more effectively and easier drill our tunnels. I'm going to first start with the superior drill hole. You can see here drill ratcheting it down. I have great grasp of the patella. Now I'm going to drill before placing my anchor. The new technology on this plant allows us to actually push the implant in without sometimes even having to use the mallet, because it's so easy to deliver it. This black suture has the needles for which ability use this to pass through the structures later in the case to repair those in tension compared to our mpfl reconstruction. This is the tension loop which will be able to actually use this to fixate the patella graft to the medial aspect of the patella. When we're setting the tension on this and actually pulling back to set the implant within the bone. We want to make sure we just pull the black sutures to do so. So we don't tension down our loop. So now we're going to fixate our ratcheting patella glide into that distal location on the patella. And we're going to drill. In place our second anchor. So you can see how easy that was to be able to actually fixate the graft into the patella using the ratcheting guide. And this new knotless fiber tack again. Now we're going to set the distal fiber tack. And you can see how well this is fixating the bone. In fact when I pull has great fixation. Now you can see we're putting the guide to be able to find shadows Point for our approach to the femur. Now in terms of Incisional approach you can make one incision or you can try to make two smaller incisions. This incision is usually about two times the size that I make on the medial aspect of the patella, especially now that we have the patella ratcheting guide. And then I'll make a small two centimeter incision over here to try to stay more minimally invasive while passing the graft. But the goal of this guide, along with x rays, to be able to find our shadows point so we can make sure that our orientation for our tunnel is in the right position for an isometric graft placement, I'm going to now make my femoral approach incision. I want to be careful to stay right at the level of the skin. Always want to be careful about the medial saphenous. I will now take a Metz. Try to develop a plane down to the medial epicondyle. I will then use my finger to identify the medial epicondyle, which is right here. And that helps me make sure that I can localize shadows point. This is the point in time that I'll actually use this guide along with x ray. I usually will have the knee at about 90 degrees of flexion and identify the perfect approach for shadows Point as I place either my guide wire or my anchor, depending upon if I'm using Knotless technology or I'm actually using the screw. Now that I have my drill pin in the correct location at Shadows Point, I will now drill, making sure to aim in the appropriate orientation. At this point, I will often make sure that I have a good plane of tissue identified around my tunnel and my guide wire to make sure that I'm able to pass the graft easier. In the case. Now, I'm going to take the reamer and drill over the guide pin. As you can see, I sometimes cycle it to make sure that I've eased of graft insertion because I really try to make sure the graph fits nicely. Now I'm going to take my fiber snare. I'm going to pass this through. And I'm going to have my assistant pull. And this will enable me to pass the graft into the tunnel later in the case. Now you can see I have everything set up the patella side with our knotless hybrid fiber tacks. And I have our socket on the femoral side to place our intraosseus screw. We can see here we have a disposable graft board. And this allows us to put tension on the graft, but also to mark the center point of the graft. This will enable us to identify the right point to put between our patella fixation sites. In this case, we're using the 6.5mm slotted tunnel. And we can see the graft passes nice and easy, which is perfect for our seven millimeter hole within the femur that we drilled. At this point, I'm going to make sure that I have a passageway for my graft around the interval of the mpfl within the medial structures. I'm going to be able to pass my hemostat down, and then I'm going to pass a fiber snare, which will enable me to pass the graft. Now we're going to pass the graft through our two tension loops right here. Now we have the area we marked. That would be the center point of the graft, right in between our tension double loops for the fixation. We're now going to tension our superior loop, which is going to fixate our graft to meals side of the patella. And we're going to do the same thing with the distal loop. Now that we've tensioned our superior and inferior tension double loops, we now have great fixation of our graft to the medial side of the patella with our knotless knee hybrid fiber tack. Now we're going to pass the graft limbs through the fiber snare, where we're going to pass this down through the layers on the medial side of the patella. This enables us to pass the graft to the femoral location that we're going to fixate. So now we can see we have the graft fixated to the medial side of the patella. Our graph limbs are entering the medial structures within the plane of the NPFL and going down toward the femoral side. We can also, later in the case, use this graph limb to fixate to the VMO, which is right here. So now we can see we have the graft which is now been passed through the medial structures. We have the hole that we drilled with the socket and our suture coming out of it. We're going to be able to pass the graft into the hole for which we have great visualization. At this point in time, you can actually pass the guidewire and then pass the graft, or you can pass the graft and subsequently the guidewire to make sure that you get a good plane to place your screw. Now we're going to use this 90 degree snap as a pulley to be able to pull the graft into the tunnel by first passing the sutures. And then we're going to pass the graft. Now I can visually see that we have the graft going into the tunnel and the graft appears very tight. Now we can see both limbs of the graft successfully going into the tunnel with appropriate tension. Now we're going to pass the guidewire, and we're going to place it in the tunnel and pass it in, where then we feel the opposite cortex and we know we're in bone. This is now going to enable us to be able to pass the screw over the guidewire, to fixate the graft on the femoral side. You can also use the tightrope, as well as the knee knotless fiber tack, to be able to fixate the graft on the femoral side as well. In review. Now that we can see we have great fixation with our inlay technique to the medial side of the patella, with our graft going through the medial structures and entering the tunnel in the femur, we have our assistant being able to hold tension on the graft on this side. And we make sure that we have a good one. Plus stability of the kneecap. So we're not over tensioning. We have our knee at 30 degrees and making sure that both the medial and lateral side of the patella have good fixation in both the medial and lateral planes, with the good end point but not over tensioned. Now we're going to take our disposable tri lobe fast thread screwdriver with our screw loaded on top of it. We're going to pass this down to our tunnel to be able to successfully fixate our graft within the femoral tunnel. We want to make sure we have tension on the graft while placing this. We want to put a little bit of force as you initially get it into the tunnel, and then usually it passes very easy. We want to make sure that we're able to see it actually go into the tunnel and to get great cortical fixation, which we can see right now. At this point in time, I will usually use a mallet to just lightly back this off. And then pass the guide wire back out. So now we can see the graft going into the femoral tunnel. And this is the hole for the screw that has great intraosseous fixation. Now I'm going to use my black suture tapes to be able to pass these through the medial structures. If I have a high riding VMO, I'm going to make sure that I be able to get a good grasp of this tissue to be able to advance it. You can see here I'm going to pass it through. And I'm going to take every single limb and pass it through. So that way I can tension this to match the tension of my graft for the tension sutures. You can also use these for additional fixation with an empty needle to be able to pass it as well and tie it down. In this case we will just use our suture tapes. Now I'm going to tie these suture tapes to be able to get great fixation of my mpfl tissues to match the tension of my graft. At this point, I have tensioned my repair back to the patella using the suture tapes. Sometimes in a pants over vest fashion, I will also pass one of the limbs around this tissue to be able to further tension. If I feel like I need that to dial it in, and I can do that both proximally and distally. The knee knotless fiber tack technology has enabled me to do this surgery in such an easy and reproducible way. The patella ratcheting clamp has enabled me to pass the suture anchors within the patella in a much easier fashion, making the surgery so much more efficient. And with this, I can actually do it in a way that minimizes any bone loss to the medial side of the patella and inherently lowers fracture risk.

MPFL Reconstruction Using the Onlay MPFL Implant System With the FastThread™ Interference Screw

Raffy Mirzayan, MD (Los Angeles, CA), demonstrates his technique for harvesting bone marrow aspirate from the proximal humerus using the Vortex™ threaded recovery needle for processing in the Angel® system.

Proximal Humerus Bone Marrow Aspiration

Speaker  I'm Rafi Mirzaian from Los Angeles, and I'll be demonstrating a bone marrow aspiration from the proximal humerus for an augmentation of a full thickness rotator cuff tear. We have a right shoulder here, and my starting point for the bone marrow harvest is going to be just off the edge of the acromion, and I can localize that with a spinal needle. And my starting point is going to be just posterior to the biceps tendon off the articular margin, where you would typically put your anteromedial anchor for the rotator cuff repair. Now, typically the entry point of this trocar has been at a 45 degree angle relative to the head, and the harvest is performed from the humeral head. What I like to do is be more parallel with the humeral shaft and advance the trocar into the humeral shaft and harvest the marrow from there. And I typically do this in a lateral decubitus position with the arm abducted at 30 degrees. So it is critical that at this point that the arm is adducted all the way down. You can see how by doing that, that trocar becomes perfectly parallel with the humeral shaft. I prefer to use the vortex needle because it provides better directional and depth control. It also provides a watertight seal, which is critical in an arthroscopic harvest of bone marrow. The vortex needle is then twisted in by hand just to break that cortical bone, and it's also important to note that I did not prepare the the tuberosity whatsoever. I left the soft tissue on it. I did not use a burr and I'm using my hand. Speaker  We're not mounting this in. We're not forcing this in. We're letting the guide find its way into the canal. And I can advance this as far as I can before I can feel. Hitting the inner cortex of the humeral shaft, which would be my stop. And you can see how deep we've actually inserted this trocar to be able to get into the shaft of the humerus. All right. So what we can do now is back this guy up. Get the fluoro in here and then shoot to show this is going down the canal. So we've now inserted our vortex needle all the way down the canal of the humerus. We will remove the trocar. And attach our vac lock syringe onto it and push back all the way. Look at that arrow. And it helps if you rotate this back and forth so you can aspirate from multiple sites through the canal. There you go. You see how quickly that aspirated. Once you're done with the aspiration, the vortex needle is removed and you can now insert your anteromedial anchor into the same hole that you just removed the needle from. So the important note here is that you do not want to do any tuberosity preparation. This includes removing of soft tissue or burning down the bone. It's also advantageous to do this at the very beginning of the case. Aspirate the bone marrow. Hand it off to the staff so they can prepare it through the angel system. So it'll be ready by the time you're done with the rotator cuff repair.

Proximal Humerus Bone Marrow Aspiration

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