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Misty Suri, MD (New Orleans, LA), presents a second-look surgery 6 weeks after CuffMend™ augmentation, showing incorporation and vascularization of ArthroFlex® human dermal allograft.
ArthroFlex is a registered trademark of LifeNet Health.

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CuffMend™ Rotator Cuff Augmentation: Second-Look Surgery at 6 Weeks

Hi, my name is Misty Surrey from New Orleans, Louisiana, and I'd like to share with you a cuff mend second look case. So our patients, a 40 year old male, he's a military recruiter and he's a recreational bodybuilder. He came in with left shoulder pain after an incident at the gym. Basically he was lifting. He had a pop in his biceps three weeks prior to presentation and he came in. So at this point on physical exam, he had pain in his biceps. He had pretty good range of motion. He was just a hair weak in his rotator cuff and a positive near positive. Hawkins and O'Brien signs on x ray. Nothing significant. No significant arthritis or dislocation or any bony changes. Now an MRI. What we see here is a small ten by ten millimeter partial thickness under surface. Tearing to the rotator cuff did have an upper border sub scap tear with a slap as well. So at this point I decided with the patient that we would proceed with a biceps tenodesis a slap repair, and to address that rotator cuff damage cuff mend augmentation of the partial thickness tearing. So in the operating room, what I found was a type eight slap. There was no evidence of any damage, and the partial thickness rotator cuff damage was confirmed. That we saw in the MRI was about 30%. On the articular side of that rotator cuff, I proceeded with an upper border subscapular repair and a decompression and a repair of that slab. Type eight to address the partial thickness articular sided cuff damage. I proceeded with a cuff mend augmentation of the rotator cuff. So here's a clip of the cuff augmentation part of the procedure. I attached the graph medially with fiber stitch RC anchors both anteriorly and posteriorly with a mattress stitch. I do prefer to use the nanoscope with this part of the case, so I can see the implants deploy on the undersurface of the rotator cuff. I used the two fiber stitches medially, and then two push locks laterally to fix the cuff bin graft. Here's what the final augmentation looked like with the graft nicely tensioned and not over tensioned. So unfortunately, five weeks after surgery, the patient fell and then fell again and had a Popeye deformity that he noticed after the second fall with a significant increase in pain. So he came in and on physical exam. At this point, he had a positive Popeye deformity with a positive speeds and positive Jurgensen signs, as well as a little bit of weakness and decreased range of motion. So an MRI was obtained at this point showing complete disruption of the proximal biceps with about three centimeters of retraction, as we can see here. And the superior aspect of the subscapular was torn as well. So at this point, the plan was to do an open subpectinata thesis with a revision repair of the superior aspect of the subscapularis. So the intraoperative finding confirmed the MRI findings of the torn biceps and the upper subscapularis tear. So I proceeded with an upper subscapular revision repair as well as an open subpectinata thesis. With the second look, I was able to see the great incorporation of the kerfman graft into the rotator cuff tissue. So to probing here you can see the the continuity of the graph to the native tissue, as well as the vascularity of the graft already at the six week time point. Now there is no inflammatory reaction at all. There was no bursitis. This is what it looked like when I put the scope in to the shoulder. So this was this is a very, very convincing second look that shows us great incorporation of this graft at this time point of six weeks. So what happens on the undersurface of the rotator cuff? You can see the complete synovial ization of the implants on the undersurface of the cuff, with no reaction whatsoever. So at the six month time point, he's doing very well. He's quite happy. He has a sane score of 90, he has zero out of ten pain and he's back to weightlifting. His motion is very good and he's got great strength in terms of cuff testing. So this was not an isolated case. I had another patient that also had a subsequent trauma after surgery that we got histology on as they went on to a shoulder arthroplasty after their massive rotator cuff repair that was augmented with cuff meant. And we can see here that there's significant revascularization, active tissue remodeling and decellularization of the graft. This was another patient, also seven months out of surgery that had an AC joint trauma that I got a second look on. That also shows excellent incorporation of the Kauffman graft. To conclude, Kauffman has been a game changer in my practice. With my experience of over 300 cases, I have found Arthur Fleck's to be the perfect combination of mechanics and biology. It's been a paradigm shift for my patients, giving my patients the best chance of healing of their rotator cuff tissue. Thank you.

CuffMend™ Rotator Cuff Augmentation: Second-Look Surgery at 6 Weeks

Rachel M. Frank, MD (Denver, CO), shares three pearls for simplifying extra-articular tenodesis procedures.

SpeedPearl: Simplifying Lateral Extra-Articular Tenodesis

When performing lateral extra articular tenodesis, I found that these three pearls make the procedure reproducible and reliable. Number one place the incision where you anticipate the anchor will go. This allows you to keep the incision small. Number two place the anchor exactly where it needs to go from an isometric perspective. Posterior and proximal to the lateral epicondyle. Number three trajectory. Aim your drill guide anterior and proximal to avoid convergence with the ACL femoral tunnel.

SpeedPearl: Simplifying Lateral Extra-Articular Tenodesis

Ryan B. Rigby, DPM (Logan, UT), demonstrates using the NanoNeedle Scope and instrumentation portfolio for ankle arthroscopy.

NanoNeedle Scope for Ankle Arthroscopy

All right. Well we're going to insert and show you a little bit on the inside of the joint. Before we do, let me highlight just some portal placements. For my placements I always use a distractor for most of these cases. But on that note, if it's a trauma case, you're not wanting to do all of that. Again, the ease of just putting this in with a needle and not having to do all the setup of a distractor is is again, one benefit to using the nano needle. If I'm doing, say it's an ankle stabilization, I want to scope. We'll use that as a situation today. I do always outline the medial malleolus, the inferior border here. This is the tibialis anterior tendon. You can feel the edge kind of that medial edge. And about a finger width up I make a medial anteromedial portal angling back into the joint. Here it's a nice safe spot, angling towards the fibula. As I insert instruments to establish that first portal, I always start on the anterior medial. I've outlined the superficial peroneal nerve here. We want to avoid that throughout the entirety of our of our procedure anterolateral portal as well. Just being able to instrument and do some work. If you need to reach further for other spurs, you can come even further lateral as well. So there's portal placement. We'll move forward. We're using the high flow sheath. We'll remove this and insert our nano needle. It does kind of click into position. We'll turn on our fluid and we'll look around a little bit and show you guys a couple things here. We'll switch over to the inside of the joint here. Okay. So basically you can see just first off we're inside the ankle joint. But how quickly I can get to the back. Whereas normally that's harder to do. The smaller 2.7 scopes bottom out. And the larger forces sometimes can't fit in here. But I'm easily all the way to the very back of the tibiotalar joint. So you can see the difference in having such a smaller instrument. And also you get a feel of that wide view and just straight on and not looking around the corners with this. So okay, so we're looking at the tibia above, the talus below. We're inserting in our our nano shaver. And we do have a little bit of some synovitis I scope every ankle stabilization because they typically nearly 100% of the time will have synovitis. So we'll work some of this out and you can see the picture quality. I mean, this is cool technology, especially being such a tiny little scope to have that kind of quality here and the ease of just using this on the iPad, if I want to, I can turn the the microphone on and tell the patient, this is all the scar tissue and inflammation that you've developed over years of spraining your ankle and just work around. And you can see, even though this this little saber shaver is a small shaver, it's still very aggressive and and works nicely. And I'll, we'll use it to show some diagnostic purposes or value of it as well here. So I just wanted to show you I left all the all the synovitis when we first entered the joint, so that I could show you just how quickly and easily that works. I do love how smooth it is in entering the joint without these teeth that will will scar the cartilage so smaller, smoother, but still aggressive and great suction. You know, one thing while we're here is just coming back. You can see how we can work towards the back of the joint, clearing out any synovitis or herniation of the syndesmosis. One thing I think we all should be documenting, based on the papers that we have now, is the syndesmosis, especially in the setting of ankle instability. And so based on several papers, one being Guyton's paper, which talks about the ability to insert a three millimeter probe into the syndesmosis would be indicative that you now have global instability laterally, medially with the deltoid and the syndesmosis. And so I always just come up and say, okay, can I insert instruments into the syndesmosis on this patient? It's negative. And I would document that in the OP report and say the syndesmosis appeared intact, I could not insert my shaver into the syndesmosis. Arthrex also has probes that come at various sizes that you can use to put in there as well, and you'll be surprised if you do that every once in a while. You'll run into one where I did not realize, hey, they have some syndesmotic instability and you can slip that shaver up in between the tibia and fibula, and you should be placing TightRope or an anterior TfL internal brace. I'll also come to the front of the fibula here and just push on it from front to back, and you can see that Syndesmosis is nice and tight there. If that was unstable, you'd be able to see a little anterior to posterior translation, but also just highlighting again the saber shaver, how I can get up into these little tight areas and just kind of clean some of this stuff out here. So there you go. That's that's the arthroscopy portion of, of this demonstration. Let me switch the portals and we'll talk just a minute, a little bit further about something I'm excited about when it comes to ankle stabilization and making decisions on which ligaments need to be, which need to be repaired. Just. And you and I have had several conversations and conversations and working on projects together. So I've switched the portals. I usually for me, I do like to have the the flat part basically facing up towards the tibia or the patient's head, and that gets me oriented on the camera. So I know that I'm looking up at the tibia. It just helps me keep orientation within the joint. Switching portals here. Come around to the medial side, get our shaver in. Still a little bit of some synovitis that we can work on. Let me clean that up a little bit further and then, you know, let's talk a bit about the deltoid. I've got some data that I'm about to it's actually been submitted for publication, finding the incidence of the deltoid being involved in ankle instability. And we're finding it's 20 to 30%, which is a lot higher than I previously was repairing. So we're working on techniques to diagnose basically identify when that actually needs to be repaired. And in the trauma world, they've called it a drive through sign. And in the acute setting, that's, I think, still very applicable and appropriate. And what that looks like is if you come over here to the medial gutter and you take a shaver, I usually, you know, in an ankle scope, we'll use even up to a four millimeter shaver. But you can come over and you can peek around the corner and you can look down at the deltoid and see if it's torn, or do this drive through sign in in the medial gutter. And if your shaver fits in between, if you can, take and insert it here, just as we've done down in between there. And it fits quite easily. And so just to give you a heads up, I did release a good portion of the deltoid just in preparation so I could show you this maneuver. But this and this is a smaller shaver, but as you can see, that fits. So if I have a four millimeter shaver and that fits in there, we know that that deltoid is a little bit incompetent. There's a little bit of some subtle instability. Maybe it's not gross instability with severe valgus tilting, but there's a little more global instability from medially to laterally. So that's the drive through sign. You'll see papers starting to come out. We have data we're publishing on this. We actually validated this in the lab in the last couple of months. But this is the medial drive through sign. And even you can sometimes just take the shaver and even just push and see the medial side open up at times. So I wanted to highlight that as well. Some of the diagnostic things. If you're not scoping your ankle stabilizations, you're missing out on a lot of pathology, and there's nothing worse than having a nice stable ankle that still hurts from all the synovitis still in there. Document the syndesmosis that it's intact and stable. You can document, of course, osteochondral defects, frequent things we encounter in ankle instability. And then the deltoid. Was the drive through sign negative or was it positive? And if it is I encourage you to go. We use a couple of FiberTaks typically here. The new knotless FiberTaks work well to do a medial deltoid repair.

NanoNeedle Scope for Ankle Arthroscopy

Gautam Yagnik, MD (Miami, FL), demonstrates a distal biceps tendon repair using the TensionTight™ button.

Distal Biceps Tendon Repair Using the TensionTight™ Button

This is Doctor Janik from Miami, Florida. Today we're going to do a distal biceps tendon repair using the tension tight button to orient you. We have a right elbow. This is proximal. This is distal. This is the radial side and the owner's side. We've marked out the antecubital fossa. And I typically make a transverse incision centered over the radial tuberosity, generally about three centimetres distal to the antecubital fossa. I have the tension tight button that comes preloaded on the inserter with our suture passer. We have our tension tight suture, a Keith needle, our spade tip drill, our appropriately sized reamer, and our seven by ten millimeter biocomposite interference screw. So once we've identified our biceps tendon, I'll get control of the tendon with an Allis clamp. And we're going to go ahead now and whipstitch the tendon using our suture here that's specially designed for the tension type button. And we've brought on our Keith Needle. Go ahead and bring our loop suture through. And you can pass it anywhere between 3 and 6 throws typically allow us to capture the tendon for our final throw. We're going to go just behind our first suture here and lock the suture into place. There we can go ahead and do our final tensioning. And we have really nice control of the distal biceps tendon here. All right. So with some of this excess tendon trimmed off we'll take our sizing guide. And we will size our tendon. And an eight millimeter socket which is pretty typical tends to be the right. So it does not fit through a seven. It goes easy through an eight. So we're going to drill an eight millimeter socket. We're going to go ahead now and load our suture into our tension type button which we've brought onto the field. You can see that it's preloaded on the Inserter with the suture passer already passed through the locking jaw. So we'll go ahead now and pass this suture. And the suture passer helps us to orient the button in the correct orientation and have the sutures passing in the correct orientation through the locking jaw. So you can see the locking jaw right here. So it can pass very easily in one direction but it will not pass backwards. So once we get the suture initially through the button there is a little thicker part of the suture. This little swedge that's coming into our field right here. So we'll go ahead and make sure that we can pass the suture through the button here, getting this little thicker swedge part through the button. And we'll also get a pull just a little more suture through. So we have both ends of the suture coming through the butt. And if we pull perpendicular to the button makes it a lot easier to pass it through the button. So once we get our button set, we're going to go ahead and clamp it here and turn our attention towards exposing the radial tuberosity. So we'll go ahead and identify the center of the radial tuberosity. And I'll kind of if I want to confirm this with fluoroscopy I can go ahead and place this pin. I want to place it by cortically. And once I pass through the second cortex I will stop there. You can use fluoroscopy here. If there's any question I encourage you to do that just to confirm that you're in an anatomic position. So once we've placed our spade tip guide pin, we're going to take our appropriately sized reamer. In this case it's an eight millimetres reamer. And it's cannulated reamer. So it goes right over our spade tip. And then. This will be a unicortical eight millimeter socket. I think it's important at this point to irrigate and remove any bone fragments in order to minimize the risk of heterotopic bone formation. And now we're ready to place our tension type button. So we're ready now to insert the tension type button. I brought this onto the field. It's important to get the orientation correct. We want the locking jaw to be facing up against the the far cortex. And to help us orient, there's a black line on the inserter. So we want this orientation. We want the button to be facing towards the ceiling here. So we'll keep this orientation. So this is the correct orientation. We do not want it going down like this. So we want it coming up like this with the black line facing up. So we're going to go ahead now and insert this into our socket. And then once I get it seated this button is slightly bigger than a traditional tension slide button. So once I get it in the opening I'll go ahead and gently feed it down into the hole, and then I'll give it some gentle taps just until I feel the button get through the cortex. So once I feel it, the button past the far cortex, I'll go ahead and unscrew the back of the inserter, remove the inserter from the field, and then I'll flip the button. So once my button has passed and flipped on the far cortex, I'm able to ensure that it's flipped here by just gently pulling up on these sutures and you can see my tendon starting to advance towards my tunnel. So I'm going to stop here. And just to confirm that my button is flipped on the far cortex, I'm going to get a lateral radiograph here. Here you can see our AP and lateral radiograph confirming excellent position on the button as it rests flat on the far cortex. As we demonstrate here on the live flora we have a very nice position of both our tunnel and our button. So I'll pull tension now on the sutures and advance the tendon to just to the opening of our socket. And at this point, in order to help Facilitate getting our tendon into the socket, we're going to flex the elbow. So we're pulling in perpendicular to our button. And our tendon is going in line and straight and dunking into the socket. So I'm going to go ahead now and do my final tensioning. And as I do this I can go ahead and really seat the entire tendon into the socket here. So sometimes you can help it with a freer. And then you go ahead and then I will also another pearl would be to take each of these sutures and tension them individually, just to make sure you get all the slack out of the system. So at this point, you can see that we have our tendon really well positioned and placed into the to the socket. It's filling the entire tunnel. I can run my freer down. If you would choose not to use a screw at this point, you can cut the sutures and you're done. If you would like to use a screw to either the tendon or further compress the tendon in the tunnel. You can go ahead and do that now. Go ahead and remove your screw. Take a knife here to cut our suture. We have removed our inserter, and you can see that we have our seven by ten millimeter biocomposite interference screw here placed adjacent to the tendon. We have excellent compression of the tendon within the socket. We have easily ten millimeter of tendon in our socket. We have excellent tension here. It's well fixed to the radial tuberosity. And at this point we've completed the procedure. We'll remove our retractors. I like to drop the tourniquet at this point make sure I have excellent hemostasis. And then we'll place this patient into a well-padded dressing. And I like to place the patients into a splint with the arm at 90 degrees of flexion and a neutral wrist rotation for approximately one week.

Distal Biceps Tendon Repair Using the TensionTight™ Button

The DualCompression hindfoot fusion nail creates a stable fusion site by providing two modes of compression for intraoperative and postoperative dynamic compression across both joints.

DualCompression Hindfoot Fusion Nail Demonstration

The Arthrex dual compression Hindfoot nail mechanism demonstration with a distal calcaneal screw and the distal tibial screw already inserted. The t-handle is attached to begin tensioning the dual compression mechanism. As the cable is tensioned, it pulls the dual mechanism slider distally until the joint is fully compressed. When the joints can no longer compress, the nitinol element begins to stretch and continues to stretch until the distal slider reaches its final position in the distal slot hears the compression sequence again in slow motion. Once it has been fully seated, the second posterior to anterior calcaneal screw is inserted to lock the distal slider in position and maintain the compression across the joint. An optional Taylor screw is then inserted to provide rotational stability of the talus. An optional second proximal tibial screw can be inserted for additional support proximally.

DualCompression Hindfoot Fusion Nail Demonstration

John Xerogeanes, MD (Atlanta, GA), demonstrates how to use reusable sliding GraftClamp instruments with the GraftPro® system during a quad tendon ACL reconstruction using FiberTag® TightRope® SB implants. The reusable GraftClamp instruments simplify graft preparation by allowing single-user graft preparation.

Quad Tendon Graft Preparation Using Sliding GraftClamp Instruments

We're going to take you through what we have on the table today. We have our standard Graph Pro, we have our fiber tag tightropes, these being ones with soft buttons. We have our our graph sizing tubes. We have our tenaculum scissors a graph. And then we have our new graph clamps. One of the downsides when you're preparing a graph is especially on a quad tendon, you need an assistant. We've tried to eliminate the need for an assistant, because you don't always have that extra person in the operating room. These are the new graft holding clamps, which eliminate the need for an assistant. You can see they look like a normal clamp just would come down. You can make it tight, but they have a sliding feature on the back. This hooks on and slides back and forth. What this allows you to do is pass a looped graph without pulling this out, or not having or allowing your assistant to pull it around the graft. So there's two types. This is the part for we used to hold the graft. And this is a part that we use to hold the card on the graph. This one is just like a normal tenaculum. And I'm going to grab the normal tenaculum that you see. And you see this one that has a little slot right here for the card, and you can hold your graft. And this is the one your assistant used to hold. Now we're going to eliminate your assistant and use the card here. Hold the graft. And then this will be under tension to hold the graft tight while you make it. So to put this on, you go 90 degrees, hook it and then you're you're you're hooked. You can see where the arrow is, which tells you which direction you're pulling and you slide over. And in that slot you can move your suture. So we've just harvested our quad tendon graft. You have the loop suture that we used on the distal portion of the graft to pull it through the Quad Pro, and when we prepare the graft, we always want to prepare the tibial side first. And that's always the proximal portion of the graft. Because this is the most severe part of the graph that you have to tubularize. And it's the most inconsistent. So the first thing we need to do is stabilize the graft and hook it to the back part. And now we have the graft hooked nicely. I often will come back here and cut this. So we keep these extra sutures out of the way. So now we'll take both posts and place them in the graft pro. You can see the arrows at the top here telling you which direction that the tension is going to go between these two. And now what we have to do is take this graft and put the the fiber tag tightrope on. So we'll grab the tibial side. We unwind this from the card. And just like we used to use the tenaculum, we're now going to use our tenaculum clamp. And again here it slides in. You can see it holds it perfectly. So put that in the middle. And you find your distal end of your fiber tag and you pop it through. So just like you would a tenaculum clamp. Now we take our graft, put the distal part in, we pinch it and slide it down. Now that we have our graft loaded onto the clamps, it can easily be transferred to the Graph Pro. Remember, you have to come in at 90 degree angle to get the clamp on. So leave a little bit of wiggle room here that you can go in. And now that we have it set we can put tension on here and we're ready to go. Usually when you're preparing a graft, your assistants are pulling tension on the part with the card on it. When you do that, the assistants often across from you. So we find it easier to change the angle of your graft pro so it holds it like this. All right. So now we're going to put the fiber tag on the proximal end of the graft. As you know the fiber tag has many advantages. The greatest advantage is its cyclic strength is incredible. So you don't get cyclic deformation like you do on regular sutures. Secondly, it's a much faster way of preparing the graft with less suture load. So we hold a little, we hold tension. And again I don't need an assistant holding tension I come right through. I hold my finger on the fiber tag and I pull this so it's nice and flat. Okay, now I slide back this way and again. Many times you would you would have to lift this out and go underneath to pass the suture loop. We don't have to do that anymore. All we do is pull up underneath, slide over and come out. And now this is ready to put my next suture in so you can see it's much faster. You save time and you don't need an assistant. So I'll show you that one more time. We pull tight. We separate. We come underneath. We use the suture to pull over. We come out and now we're ready to do our next throw. Now we're ready to lock the fiber tag. Tightrope construct in place. So we come underneath through the hole, and then we come down right next to that point. And again you see the tension that this holds for us. So it makes it very easy for us to pull tension. Now you could also pass from the opposite side. So if you're left handed it's often easier to pass from left to right. Then you can use your your left hand to put the needle through the tendon. So in this case again you pull up and under you slide across, you come out and you're ready to place your last piercing. So we go through, we come down, we tubularize the graft. Now, when we. If we want to come back, if you're ambidextrous, you can come back, go up and over, and then you don't have to slide things back and forth. And now we tie the sutures. Now, this is a very flat, lying suture. Some people like to bury the knot. I tend not to, because I think it's just not very big. So we get a nice flat knot. And then we cut the end and we're good to go. So now that we've prepared one end of the graft, you can take the tenaculum clamp off and use it to hold the other end of the graft. We secure this with the traditional alligator type clamp. Be careful that the clamp itself grabs only the card and not the sutures between the card. You don't want to damage any of the sutures, so grab the card itself. So now we're going to prepare the femoral side of the graft in a similar fashion that we did the other side, we hold tension on the fiber tag we come down through. And we get this place nice and flat. So now that we place the fiber tag, we have two options on how we want to pass the sutures. We can pass closest to us like you saw on this end of the graft, or we can pass away from us. So to pass away from us, we pull under the graft. We slide the suture Over. We push over. And we're ready to pass. Now, you saw one of the reasons why I don't love it this way. Because it can get caught on the card. But you have personal preference. And if you choose to pass it that way, it will work on either side of the graft. And again, I'll show you one more time. So again, if we go proximal, if we go to the top part of the graft, we come in, we hold over and we come underneath. And if you pull tension on the graft, you're able to avoid grabbing the card. So again, it works either way. It just has to do with personal preference. So now we're ready to tie. We take the needle off the graft suture and we're going to. Again put a nice flat. Not here. And this suture ties very flat. So it's not bulky at all. Again make sure you're tying a square knot here. And then your graft is ready to put in the graft tube and place in the patient. We prepared this graft just like an assistant was helping me. Some people feel more comfortable with the graft perpendicular to them. And you can certainly do it this way, because, again, you don't need an assistant holding a graft off to the side. It's again your personal preference.

Quad Tendon Graft Preparation Using Sliding GraftClamp Instruments

At the Complex and Revision Shoulder Arthroplasty Surgery course, Brian C. Werner, MD (Charlottesville, VA), discusses the rationale for using the Virtual Implant Positioning™ (VIP™) system for preoperative surgical planning for total shoulder arthroplasty cases.

Hidden

Taking Advantage of Preoperative Planning for Total Shoulder Arthroplasty

OrthoPedia: Taking Advantage of Preoperative Planning for Total Shoulder Arthroplasty

Andrew L. Clavenna, MD (Dallas, TX), discusses the surgical use of the GraftNet™ XL bone collection device for spine procedures.

GraftNet™ XL Device for Spine Procedures

I'm Andrew Clavenna from Dallas, Texas, here to demonstrate the Graphnet XL. This is a case standard mis-tlif type case important when collecting bone dust that use different suction lines so that we don't put soft tissue into the bone dust collector. So here we are. Tube retractor facet joint cephalad caudal. And I'm just going to clean off some of the soft tissue from this facet joint as we would standard in any case. Here's where simply having the multi-port allows us to switch over to the suction tubing to collect our bone graft. Obviously, a three millimeter matchstick two fluted device is better, as studies have shown flute size does make a difference. Definitely don't want to use like a diamond bit, bur as our cell viability would be much less benefit of that. Graphnet XL is that the mesh collector allows us to irrigate without worry that we're diluting our bone graft. Clean. Classically, all this bone would be thrown away and wasted and allowing us to harvest this and use it for our fusion has shown that this bone has mesenchymal cells. And osteogenic potential to facilitate our fusion during our tlif. So I've removed most of the inferior articular process of L4, and now going through the superior articular process of L5. One of the advantages of the graphnet XL is that it does have a three foot suction tubing attachment to get your hand away from the collection device, decreasing weight on your hand to minimally change how you normally operate, as well as allowing the scrub tech direct visualization of your collected bone grafts so they can notify you if you're filling up. The device does allow for a large volume of collection. It also has a clip attached so that the scrub tech can clip it to the mayo, or hang it from the mayo so that it's out of the way and you don't have to worry about it falling onto the floor and contaminating the sterility and using the drill to remove this bone. It allows us to get down to that cortical edge and overall minimize the use of the kerosene. Less kerosene. Use less fatigue you have to worry about in your hands. It's important after you're done collecting your bone dust, your suction tubing attachment, especially if you're using the three foot adapter, has extra dust in it, and you'll want to collect that by simply irrigating through the suction device. As you can see, all that extra irrigation is suctioned out and we've got our bone graft in the mesh bag. So after you're done harvesting your bone graft and you've irrigated your suction tubing, make sure and turn off your suction to decrease the vacuum on the container. And then simply counterclockwise turn of the lid allows the lid to be disengaged. This gives you access to the mesh bag in the center. Your bone graft still will be somewhat hydrated, so you can simply squeeze that mesh bag to get further liquid off of your bone graft. Once you're ready to get the bone graft out of the mesh bag, simply invert the mesh bag to expel your bone graft. You can put your fingers inside to tint up the mesh bag to allow you to scrape off any residual bone graft. There's a fair bit of bone graft here, and this is from just taking out a unilateral facet joint. Graphnet Excel not only allows you to collect a large amount of bone graft, but the handling characteristics allow for mobility. Obviously this then can be added to a substrate to increase your overall graft volume, such as PRP or DBM. So to illustrate how much bone graft you can get. Again, this is just from a unilateral facet harvest in a five cc syringe. We are able to decrease the overall cost and potentially less use of extenders.

GraftNet™ XL Device for Spine Procedures

DynaNite® CT nitinol staples deliver active compression for secure sternal closure, applying proven orthopedic fixation principles to cardiothoracic surgery. With two low- profile staple size options, the system offers flexibility to accommodate patient anatomy and surgical technique. Engineered to ensure consistent sternal stability throughout postoperative recovery, DynaNite CT staples work in combination with FiberTape® cerclage to deliver a comprehensive solution for sternotomy repair.

DynaNite® CT for Sternotomy Closure

Low profile Superelastic dynamite CT. Nitinol staples are available in two sizes, designed to accommodate a range of patient anatomies before closure. Measure the thickness of each sternal have to ensure secure fixation without compromising the posterior cortex. Choose a staple that is at least two millimetres less than the thickness of the sternum. With fibertape sternal closure completed, the dynamite drill guide is then positioned centered and perpendicular, setting the stage for precise implantation. The dynamite CT system features a specialized positive stop drill bit designed to safely drill into the sternum, preventing overpenetration to protect underlying tissues using the loading device. The dynamite staple legs are adjusted to match the width of the drill guide. The staple leg should be in parallel or near parallel position to facilitate compression of the sternotomy once inserted. Once seated, the device is released, allowing the nitinol to return to its original shape, delivering targeted active compression to the sternal body. A tamp ensures the staple is fully seated. Additional staples can be placed as needed as an adjunct to fibertape sternal closure. A minimum of two staples is recommended to optimize fixation and enhance resistance to lateral distraction of a median sternotomy. Dynamite CT, nitinol staples and the Fibertape sternal closure system deliver the strength, compression, and flexibility needed to optimally personalize sternal closure for every patient.

DynaNite® CT for Sternotomy Closure

Raymond J. Gardocki, MD (Nashville, TN), provides an in-depth overview of the anatomical orientation through an endoscope lens during an endoscopic transforaminal approach for discectomy.

Voyage Into Kambin’s Prism

Welcome everyone. I'm Doctor Ray Gardocki, an orthopedic spine surgeon from Nashville, Tennessee, specializing in minimally invasive and endoscopic spine surgery. Today, I'm excited to take a deep dive into understanding the anatomical orientation through the lens of an endoscope. During a transforaminal approach, we'll explore Kambin's prism at L4 five and the surrounding anatomical structures. Just as technology has revolutionized how we navigate our world, it's also revolutionizing the way we understand anatomy. Now, a traditional surgeon performing open procedures can use all the exposed landmarks to identify their location. Imagine using a map to navigate a city. If you don't know where you are, you start with a wide overview of the entire city. Then zoom in to your specific focal point. You can look at cross streets and surrounding buildings to pinpoint a specific intersection. This broad perspective represents how traditional open surgery allows surgeons to see and navigate using a wide field of vision. In contrast, endoscopic surgery requires a different approach in perspective. Think of it as navigating the same city with a map that's permanently zoomed in. In this example, the endoscopic surgeon only has a view of a small section of the curb and needs to understand where they are and what surrounds them using this zoomed in view. During this step, I am looking for a landing spot or home through lateral and AP fluoroscopic imaging. One of the major difficulties surgeons have when transitioning to transfemoral endoscopic surgery from open midline surgery is orientation. Surgeons understand the anatomy of the spine. They know the relationships between the pedicle, the traversing nerve root, the exiting nerve root, the disc space, and the superior articular process. They're just accustomed to looking at those structures from a posterior midline approach. As soon as they look at these structures through a transforaminal approach, they become disoriented. The best way I can convey this concept is with the aid of this visual. Now, when you look at this image, it makes no sense. Why is there a floating rock above a cliff in the background? But once you change the image to a familiar perspective, it all makes sense. The transforaminal approach is much like the orientation of this image. The anatomy doesn't change, just the perspective. The traversing route is still medial to the medial wall of the pedicle. The disc is still above the pedicle. The exiting route is still below the cranial pedicle, and the superior articular process still extends out from the top of the pedicle, forming an arch in the foramen. The anatomy and the relationships don't change, only the perspective. Once you become accustomed to this perspective, everything becomes familiar again. So let's take a journey into Kambin's prism, as seen through an endoscopic approach to l45. We're all familiar with Kambin's triangle. It's defined by the exiting root, the traversing root, and the endplate of the caudal vertebral body. This outlines the floor of the triangular working zone. However, this region is better described as a three dimensional space or prism that changes as we change the level we're working. There tends to be significant overhang from the lateral aspect of the superior articular process at L4 five and L5 S1, enough so that bone removal of the sap is commonly required to access the lateral recess at these two levels. Bone removal is rarely needed above L4 when there is no underlying foraminal stenosis. This is the L5 L5 superior articular process, little strip of the L5 vertebral body and endplate. This is the sap in Wagner's arch. Here is the disc. The floor of the foramen and the entry into the canal. The traversing nerve root is in here and the exiting root is up there. When performing transforaminal spine surgery, it's crucial to ensure that there's enough room for both the instruments and the dorsal root ganglion in the foramen. Too much pressure on the DRG can cause discomfort and potentially lead to radiculitis. This is why I prefer my neuromonitoring for Transforaminal approach to be an awake patient. If you put excessive pressure on the DRG, the patient will respond. Additionally, when dealing with Cranially migrated fragments, we need a slightly different technique, as working more cranially in the foramen increases the risk to the DRG of compression. Now, once you find the pedicle, you know where everything else is. The pedicle is the lighthouse of the spine. From here the arch superior articular process and disc are easily recognizable. This is your home. If you're ever feeling lost, just return to home as a quick pearl. If you did your approach without making a large fascial defect, the soft tissue and bony foramen will hold the scope docked in the frame in the home location. Now that you understand how to visualize kambin's prism through an endoscopic transforaminal approach at L4 five, let's discuss different disc pathologies. Here is a typical contained posterolateral herniation that displaces the traversing root dorsally. Looking up at this herniation from the floor of the foramen allows you to Allows you to visualize the lateral side of the herniation protruding up from the disc space to the sap. This is a good beginner case. You will enter the base of the herniation laterally and remove disc material from under the annulus. This will continue until the traversing root drops down to the field of view, pulsates to heartbeat and is freely mobile. Here is an intraforaminal herniation within the foramen with proper targeting. The scope will end directly upon the herniation, making this another good beginner case. If the herniation is cranially extruded and dorsally displacing the DRG on the existing root, you must visualize the bony floor of the foramen, which is the back of the cranial vertebral body underneath the DRG and exiting root. Far lateral herniations are more technically challenging because you need to turn the scope around 180 degrees, and there is no bony architecture to hold the cannula and endoscope in place. This means that you need to control both the depth and rotation of the cannula, the endoscope and the instrument all at the same time. The DRG often needs to be retracted to expose the herniation, which induces a 20% risk of radiculitis between the root retraction and the reperfusion of the DRG. You must visualize the bony floor of the foramen, which is the back of the cranial vertebral body underneath the DRG and exiting root to ensure an adequate decompression. The endoscopic approach offers easy and direct access to most pathologies through an eight millimetres incision, minimizing disruption to the muscles and other soft tissues. This technique results in reduced blood loss, less muscle disruption, faster healing, and allows for a quicker return to work and normal activities. And there's no need for postoperative narcotics. Now that you have a comprehensive understanding of visualizing Camden's prism through an endoscopic transforaminal approach at L4 five, as well as the anatomic nuances and techniques for different herniation locations, you're better equipped to enhance your surgical precision and patient outcomes. Thank you.

Voyage Into Kambin’s Prism

Asheesh Bedi, MD (Ann Arbor, MI), demonstrates a comprehensive cam resection of the femoral neck using the Hip DiamondCut™ burr.

Femoral Neck Cam Resection Using the Hip DiamondCut™ Burr

Today, I wanted to feature two great products that you have as part of your armamentarium for hip arthroscopy and preservation surgery from Arthrex. And that's the four and the 5.0mm diamond cut burs. So here's a close up. Some of the huge advantages here is its ability to work as a finishing bur. It can function well on hard bone or soft bone with great control and precision, and it avoids skipping, which is sometimes what happens on those harder surfaces with a fluted bur. It works reliably in both forward and reverse. Another advantage over fluted technology is sometimes the ability for it to protect and not wrap soft tissue in the capsule, which is at a premium during hip arthroscopy. All right. So now we have this more focused view. And just to orient everyone this is a right hip. We've completed our central compartment work as you can see here. Nice labral repair using the knotless fiber tack anchors getting a good suction seal of that labrum. And now we're just working to our peripheral compartment. There's our acetabular sided capsular limb and the rectus. And here's our femoral capsule here. And we can now start to demarcate for our camera section. Generally speaking for me I like to start superolaterally here right adjacent to the labrum. And here with this diamond burr, we can set a margin. But again, one of the advantages here is this nice demarcation and control even on hard bone in a young patient where we can set an edge and you can see it doesn't skip. I tend to use the labrum as a guide to set that physeal scar. And here I'm just going to work to define that margin of our proximal resection. You can work fairly closely here to the acetabular edge here. And again based on the position of flexion you have, you can set that margin rather nicely here. Here as we go a little bit more anteriorly I come a little further away from the labrum to set that normal angle of the physeal scar. As you can see that defines that nice proximal edge. And we know that everything proximal to that we're going to designate an important weight bearing cartilage. I'll sort of deliberately here, as you can see come in close proximity to this femoral sided capsule. And you can see not only does the hood protect us, but this diamond surface is not wrapping up that capsule as I work in close proximity, which is more likely to occur with your fluid at burs. From there, we can continue to work our camera section here. I can switch deliberately here from reverse to forward, no difference in its efficiency in resecting and setting that margin for our camera section working here from proximal to distal along the edge. We'll continue to work here. You can see here nicely. We can work right next to that labrum with good control. I'm basically abutting the labrum here laterally and can continue to work right around the corner here, even superolaterally up near our retinacular vessels. Here we can change our view a little bit. We'll rotate our eyes. You can see here we can work more medially. Oftentimes this bone here medially is a little bit softer. And this is where the fluidic bur can sometimes gouge or resect particularly in softer bone. But here our diamond burr has excellent control as we continue that resection working from proximal to distal right here towards our capsule. As you see here as I'm resecting bone, one huge advantage is we're not getting the snowstorm effect or the snow globe effect, which can sometimes obscure your view. I'm modulating the suction here, but I have an excellent view and control the entire time. And that polish and design of that diamond burr surface has specifically been designed to minimize the risk of that snow globe effect. You can see here we're working in the camera section from proximal to distal. And I can continue to work my way distally preserving this proximal convexity and then working distally here now to a more concave resection. At this point as I'm continuing to push the capsule away, I think you can see nicely even without changing the leg flexion. I'm not wrapping up the capsule at all. As we continue that resection medially and distally. Just for a moment, I'll show the view. Here you can see where we've defined that proximal margin of resection. Nice margin. And we can continue to work distally here. So as you can see we've continuing our cam resection. We've set our proximal margin. This actually is a pretty good view as you can see here of the Cam lesion. This loss of offset here and asphericity here. As we move over that direction you can even see your superolateral extent of the Cam lesion. Those are your perfusing retinacular vessels there. For the sake of this video, we've deliberately done a little mini T here so that we can see and visualize this camera section to show the value of this burr, But here I can work with great precision and even drive here up in superolaterally work right next to the labrum with great safety. Here I'm going to continue that resection proximally. And here we can work right up and next to the retinacular vessels here and actually remove that bone without worrying about winding up those vessels, even those anterior perfusing vessels. Then here, as we work our way back, I can set another margin here of resection. Again. Good control. It doesn't skip. Finishes medially and laterally with precision. And we'll continue to define that cam lesion so that we don't stop proximally. But we restore that offset here distally all the way along the head and neck junction as well. You can see it works very well working from proximal to distal. And we'll continue to work distally right here towards the distal neck. So we feel like we've restored normal sphericity and offset in all of these different planes. I'll deliberately here bring the the bur as I wouldn't right up on the capsule here deliberately try to wrap up the capsule with the bur. And if you notice it's avoiding that wrap up even when I'm intentionally trying to go towards and blur the soft tissue. It just won't wrap up the tissue the way a fluted burr does. So truly an inherent additional layer of protection to protect the capsule for your later closure. So, as you can see here, as we've progressed through our camera section, we've got a nice proximal demarcated margin for the weight bearing cartilage. We've restored offset and sphericity here in the area of the typical Cam deformity. We've had a great control here with this diamond burr. You can polish out any areas as you're inspecting around to make sure that you've been thorough in all planes. You can actually see a little impingement cyst here that we have great control over to make sure that we've gone to the right depth there. So this is a nice and thorough camera section that's well controlled using this diamond Burr technology that allows us to do an excellent pincer resection proximally and an excellent cam resection distally. Now, as you can see, because we've preserved our capsule so nicely, we can just come here and nicely repair this mini T side to side working from here to here. And then we still have our proximal capsular flap for our inner portal closure.

Femoral Neck Cam Resection Using the Hip DiamondCut™ Burr

Peter Borden, MD (Torrance, CA), demonstrates repairing a small rotator cuff tear using Self-Punching Double-Loaded Knotless 2.6 FiberTak® soft anchors.

Small Rotator Cuff Repair Using Double-Loaded Knotless 2.6 FiberTak® Soft Anchors

Hi, this is Peter Borden from Los Angeles, California. I'm going to demonstrate with you today the use of the 2.6 FiberTak anchor. Using two anchors for a simple rotator cuff repair. This is a left shoulder, and we have a small laterally based tear. We are going to plan to put one anchor here and one anchor here, right on the edge of the greater tuberosity here. We are going to repair that in a single row fashion. For this case we're utilizing the NanoScope. We've got this ultra wide NanoScope view currently of the greater tuberosity and the small cuff tear. You can see the extent of the cuff tear, but you can see the entire greater tuberosity from front to back in this one view. I can show you with a press of a button that we can cycle through a 70 degree view, so we can look at it from the side standpoint. I can also cycle away from that and do a standard 30 degree view as well. But notice how when we go to the Pano view, we just get a much more global view of the greater tuberosity. Here we've added an ASL portal for suture management. I would like to be able to put both anchors. One anchor here and one anchor here. We're going to go ahead and retrieve our working sutures one at a time, out our lateral portal, and then we'll take the Scorpion. I'm going to add the working stitch to the side loader as we come in. So I'm going to go ahead and take a feel and see how much cuff tissue I want to grab. And I want to pull and reduce. I'm going to go into the anterior extent of the tear. That looks good. I'm going to do one there and let's go ahead and pull that. So we got the first pass done. I'm going to move that out of our working portal for suture management. So now we'll retrieve our blue white working stitch. We will add the second working stitch to the Scorpion. We're going to hold our suture and do our second pass, making sure we stay on the correct side of all the sutures. And we're going to come in and we're going to make an analogous pass. And I'm going to take all these and for suture management purposes, and we're going to take everything out of our ASL portal. There's our passes. So now we're localizing our posterior anchor placement here. So I want to be right off the edge. Kind of similar to my other anchor. And then I'll check the anchor again and make sure I can lift the arm up and I can. So we placed our anchor. We're going to retrieve the black and blue working suture. Now we're going to load a Scorpion passer. We will take a look at our spread. So I don't want to hit the other suture from the first anchor. So I'm going to keep an eye on everything. I'm going to go in, go above it, look and see where my other pass was. There's my other pass. I'm going to go just adjacent to that. So we're going to come in and we're going to go ahead and take our second pass. We will fire it, retrieve it. So we got two sutures there. We're ready to convert. So I'm going to go in I'm going to retrieve this guy. We have the loop suture for conversion of the anchor. At this point I'm going to go ahead and take this. Put it through the loop. And we're we'll make sure that it's where the purple mark is. That's the purple mark. Both sutures are through the shuttle loop, and I've got this ready to go. So I will go ahead and convert this. We will utilize the shuttle suture in order to put a little tension on the loop on the working repair sutures so that we have a little counter tension and this little counter tension that we're doing on here. It just helps us keep this from getting all twisted up. And as I bring it in, look how nice and straight it kept my repair sutures on that tissue. And now that I've got this scenario here, I could remove this suture that was helping me maintain the orientation of the sutures. And now we're going to take both of these sutures, and we will go ahead and seal that down to bone. We will go ahead and use the Mega loader to load our repair sutures in the cutter, and we'll come in and we'll go down to the anchor, give another little gentle tug. Now we'll do the same thing with the other sutures. So that's perfect. We will cut this suture and get out of here. We've got this single row, lateral row repair of the rotator cuff. We've got great fixation of the cuff tissue to the greater tuberosity.

Small Rotator Cuff Repair Using Double-Loaded Knotless 2.6 FiberTak® Soft Anchors

Peter J. Millett, MD (Vail, CO), uses the Knotless 1.8 FiberTak® implant system in a cadaveric demonstration of a knotless Bankart repair. Dr. Millett reviews a range of tips and pearls from portal placement to sequential repair tensioning. Tensionable Knotless FiberTak implants of varying colors provide multiple points of fixation to restore anatomic tension to the glenohumeral soft tissue.

Tensionable Knotless Bankart Repair Using the Knotless 1.8 FiberTak® Implant System

Hello, I'm Peter Millett from Vail, Colorado. Today we're going to demonstrate an arthroscopic bankart repair using the 1.8mm Knotless fiber implant system. So we've established our posterior portal, and I'm going to demonstrate the new five millimeter percutaneous cannula. I'll put a spinal needle in first. And then this can be placed over a guidewire. So it allows you to place the anchors wherever you want. So this will be a high one here. At this point I'll have my assistant just hold the scope. We'll pull out the center portion of the needle, feed the little wire down. We'll just make a little nick in the skin. Here for about 4 to 5mm is usually sufficient. And then this cannula can just go right over it. And you can place this anywhere, anywhere you need. And the nice thing is that the 1.8 anchors will fit through that. Great. So that's our first portal there. So now we've established our second portal here. This is an 8.25mm cannula. I like to put it just over the subscapularis. Usually you can reach most of the glenoid with with this approach. Occasionally, if you need a really low anchor, you can go in percutaneously using this five millimetres cannula with the same technique. But in this case, I think we'll be okay with these two two cannulas. The more medial this is, the easier it is to pass it around the tissue. The more lateral it is, the easier it is to insert your anchor. So you have to kind of take that into consideration. Then what we'll do is we'll mobilize all the labrum and the capsule here, which we've done. My assistant just kind of pull back on the arm a little bit. And that helps to visualize that. Sometimes we use a 70 degree scope or this scope viewing from the back, just to help us see this as well. You want to have it mobilized until basically you can until you can see the subscapularis fibers underneath it. Now we're going to demonstrate putting our first anchor. And this is the curved guide for the 1.8mm anchor. We'll place it in through our lower cannula here. If you put the obturator in, it just helps to decrease any fluid extravasation. And then once it's in position, ideally we'll get it up on the glenoid face. And then I'll tap it with a mallet just to secure it on the glenoid here. And then we'll come in with the flexible drill. And then usually this is this phone's kind of soft, but in a young patient, I would cycle the drill 3 to 4 times to make sure you clear all the bone debris out of it. Now, we'll come in with our with our anchor. This is the 1.8mm knotless fiber tack anchor. And there's a little recess in the in the drill guide here. And it's important to line the little handle here up with that so that it slides down properly. And then we'll insert it by hand for a few millimeters and then finish it off by tapping it in place. And this just bottoms out on the inserter. I'd like to just check the prongs, make sure they're intact, and then we'll remove the inserter at that point, and then we can pull back on the anchor and make sure that it seats properly. So now our anchor is inserted. You'll see that there's three sutures in this 1.8mm knotless fiber tack anchor. The repair suture in this case is blue. They come in different colors in this system to help with differentiating suture management. But you want to retrieve the repair suture out through the superior cannula, and then you'll leave the shuttling suture here in place out through the inferior cannula. And try not to touch these sutures very much so that they don't get extra twists in them or get damaged at all. At this point, we'll then come in with a lasso. This is a 25 degree left curved. So what I do is oftentimes I'll just kind of stabilize the tissue with the grasper. And then I'll come in perpendicular to the capsule and pop through and then rotate my hand around until I see it in the defect there, and then retrieve the. Retrieve the wire out through the superior cannula. Then at this point, we'll just shuttle this repair suture back through around the capsule and labrum, and you untwist this. Then we'll just retrieve that repair suture out through the capsule and labrum. And again we try not to twist these at all. So there that's out. Now one thing I do is I just kind of milk the suture a little bit to take any longitudinal twists out of it. And then I'll put this park this over to one side, and at the same time I'll take the shuttling suture here, separate that. I always separate it from the cannula out. So I'm not putting twists into it and then move it back and forth. Some people call it a floss technique, and then we'll take an extra suture. At this point this is a counter-traction suture. Shorten the loop here and then we'll we'll pass our repair suture through through the loop and then fold it. There's a little mark purple mark right there. Fold it to that point. Now I'm just going to convert the suture. So I'll just do this kind of start off slowly. Make sure the suture is entering the cannula properly. And then just pull it out. That converts it. Grab the end of the repair suture. And then at this point now I can pull back on this traction suture. It puts tension into the loop and it makes it go in nice and smoothly and without any twisting. And you can see that I'm going to back up here so we can see that being delivered into the joint here. So there you can see it. It's getting get it pretty close. So just before we tighten it up finally what I can do is I can come in with my grasper again and just grasp the soft tissue and pull it up and reduce it like that. Pull it tight. You see, you still have this traction suture here. We can remove that at this point. And we can use that again. Use it over and over again for the next ones. And then we'll just do our final tightening here. And we've got a nice shift and we've got a nice restoration of the capsule labral junction and nice bumper in the front of the shoulder. So at this point you have the option to either cut the suture or you can leave it and then do sequential tensioning. I think if you're going to do sequential tensioning sometimes taking this out of the cannula can be helpful. So you don't get tangled on the other sutures. So just put a switching stick in, pull the cannula out and then we can grab the suture. And then we can put the cannula back in. And now we have our suture kind of out of harm's way. And we can put our next anchor in without without worrying about getting tangled or twisted. Great. So we've got our first anchor in. Now we're going to place our second anchor. This one's a little bit easier. Usually the lowest one's typically the most challenging. Typically we'll place it about the first one around 5:00, then 4:00 and 3:00 or so. Place the guide in place. Tap it up on the face of the glenoid. Secure it and we'll come in with our flexible drill. And then it's important to pull the drill back beyond that little opening in the. In the insertion sheath so the bone debris can be removed from the. From the tunnel. And at this point then we're going to come in with our second 1.8mm knotless fiber tech. This one has a different color repair suture. So we'll be able to distinguish those again. You'll line up this with the the recess part of the inserter here so that it goes around the curve properly and then insert it by hand initially for the first few millimeters to get it started, and then tap it in place. Remove the grommet. Tap it to disengage it. I'll come in with my retriever. This is a mini kingfisher retriever. And again you have your repair suture and then you have your shuttling suture. So the repair suture in this case is is white and light blue. So we'll retrieve that separately out of the superior cannula. And again now we'll come in with my 25 degree left curved lasso I hold the these sutures tight so I don't damage them at all while I'm inserting this. And I'll just back this wire up. And at this point I can grab this tissue, kind of pull up on it a little bit so it has good tension. And again, go perpendicular to the capsule and come around, hit the glenoid, and then we'll pop through just below our anchor and then retrieve the retrieve the wire out the superior cannula. And then we'll shuttle our repair suture back down through through the cannula and then around the capsule and labrum. Okay. So at this point again we'll we'll separate these sutures so that it's so that they don't get twisted. Just put the repair suture to one side and the shuttling suture to the other side. Strip this a little bit to make sure there's no longitudinal twists in it. Now we'll come in with that counter-traction suture. So this goes between goes between those two sutures, between the repair suture and the shuttling suture. Now we'll just convert the anchor. So again you fold it over. There's a little blue mark right there that's appropriate. And then at this point we'll convert it. And now we have this this traction suture. Again it makes it a lot smoother a lot less chance that you're going to get tangled or twisted. And it really just makes the procedure a lot, a lot simpler. So at this point we have our suture almost fully tensioned. I'll come in again and grab the soft tissue, and I can get it right to where I want it to be. And then at this point, I then can remove that traction suture, and then we can get the final tension on our repair stitch here, and we can retension our first one if we want. And so you can get a little bit more tension out of that. So now we've completed putting all our anchors in. This is our lowest one here, our middle one, our second middle one and our top one. We put four anchors in this repair. I usually use four. Sometimes if it's a really big tear, even five, you can see how it's restored the capsule labral tissue here. Now what we'll do is retrieve our repair sutures so that we can go ahead and tension them again. We'll pull them all out through the cannula, and then after that, after we tension them, we'll we'll then go ahead and and cut each suture. So we'll just start at the bottom here you can see we can retension that a little bit. We looked at this in the lab recently and showed that you get about an extra millimeter or so when you do this. Because as you can imagine, as you pull each suture up and put each anchor in, it helps to spread the force over the whole construct. So there we've tensioned each one individually. So now they're all tight. So at this point we'll then we'll just cut each one sequentially. Just a little pearl. When you're using the cutter it's always important to cut it right in the center. You don't want to cut it off to the side like that. You'll get frayed edges. So cut it right in the center. Here's our our final repair for anchors for bankart repair. This is with the 1.8 Knotless. Fiber tech gives a very nice low profile repair. You get multiple points of fixation, minimal bone resection, very strong. You can retention it at the end as well, which I think is a nice advantage. Hope this helps you in the care of your patients. Thanks a lot.

Tensionable Knotless Bankart Repair Using the Knotless 1.8 FiberTak® Implant System

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