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NanoNeedle™ Scope 2.0
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Pitcher's Recovery

Jonathan A. Godin, MD (Vail, CO), performs a segmental meniscal allograft transplantation (MAT) using the segmental meniscus procedure pack to treat a midbody meniscal defect. Dr. Godin also shares key tips and technical pearls for using the meniscus template included in the procedure pack to ensure optimal graft matching.

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Segmental Meniscal Allograft Transplantation Using the Segmental Meniscus Procedure Pack

Speaker  This is John Golden from the Stomach Clinic in Vail, Colorado. We're going to go over the components that comprise the segmental M.a.t. procedure pack. There are many suture tape links with or without needles, with four distinct colors for the corresponding four quadrants of the graft. And then there are also associated mini suture tape links without needles that will go into the graft. In addition, there is a free needle with a nitinol loop, and one of the most unique aspects of this is the meniscus template for the meniscus template. This is made of the same material as that used for the passport, and you can see distinct radii of curvature throughout the graft template. Four different quadrants showing different radii of curvature that would fit most appropriately in the segmental meniscus defect. Another key feature is that you can trim this to size for the height of the meniscus. Lastly, you can pass a suture through this so that you have complete control of the template within the knee joint for easy placement and extraction. We're starting the prep on a segmental M80. This is a right knee, and we're working on a mid body segmental defect here. We've begun some of the prep with biters and the torpedo shaver. And just doing the finishing touches on that right now with the shaver first. And you can use a combination of different biters to finish your prep work. Speaker  Key here is going to be coming from your control departmental portal to finish to have the best angle to work around the tibial spines. So you can kind of see we're finishing getting an appropriate. You want to leave at least a millimeter of rim if you can. And then another key here is keeping the edges, the anterior and posterior edges as sharp as you can to maximize some of the surface area. And then you'll want to mimic the pattern on your allograft on the back table. As is commonplace, we have fenestrated the proximal MCL to help with our exposure for this procedure helps with a valgus force applied for your visualization. So I'm going to do is switch portals view from our lateral portal to see and measure our defect. Now with the SCR ruler. So we're getting our anterior to posterior dimension here which on this is about a 19 or so nice clean edges nice rim there to repair and have healing to that. You notice the cartilage in the specimen is quite good. The other thing that I'll point out is that we've got our approach for our inside out, a typical inside out. I tend to use a probe to mark the joint line, and I make a third of the incision above that, two thirds below. Speaker  Once we get through the subcutaneous tissue, we're identifying the Sartorius fascia here. And I've kind of come in line with that to retract the hamstrings. And then below that, we're going to have our layer of the capsule and the postero medial gastrocnemius. So there are obviously different dimensions here. The most important is going to be your anterior to posterior. In my opinion, you don't want to short that and have too much strain across the radial repair sites anteriorly and posteriorly. And so getting that is the most vital. You're going to have a size matched graft. And so but sometimes the width is going to be variable. And it doesn't matter as much if there's nothing you can do. If this is a little bit inset after you place the graft in. If it's a little if there's a little excess, if you want just for appearance, it can be trimmed. And then the last is going to be the height. And so that's where we'll use the template. And we can size that more appropriately, which then allows us to size the allograft on the back table before we put it in. Once you have your segmental defect prepped arthroscopically, you can go to the back table. What we've done here is removed a right medial meniscus allograft from the corresponding bone. And then we have the template. Speaker  And so you'll want to use the template to identify the corresponding radius of curvature that best fits the area that you'll be transplanting. And so you can see the shorter radius of curvature here all the way to the longest. And if we put this on the corresponding area that we would be transplanting for this patient. Zone two has the best fit whereas three. And certainly this fourth zone here don't match the radius of curvature as well. And then we have the sizing. And so we can again use that ruler that we used arthroscopically. And within that zone we'll be able to measure to the same length. In this case it measured a 19. So I'll go about a 20 to size the template. And then we can mark the template with a stay stitch and put it into the joint to make sure that the fit is perfect. One thing I would note here, I tried to get pretty right angles on my defect. If you have more of a lower angle than. I would cut that appropriately to try to match when it fits in the joint. And so now we have a 20 millimeter portion on the outer rim for our template here. And I'm going to put a tag stitch in this. Personally, I think the anterosuperior quadrant is the easiest to place. So what we've done is made a small about a millimeter trim in the anterior to posterior position. Speaker  And then we've cut the template at the top of our fourth marking. And the nice thing with this material is the durability and the ease with which you can go in and out. And then I pass this, this link again in it. And you can see that the, the material stands up to that quite easily. So here I'm going to check the anterior posterior position, which looks quite good front to back. And then this view here I'll be checking the height. If this were placed in like that. So in standard fashion, we've placed our mini tape links into the four quadrants Anterosuperior, Anteroinferior, Posterosuperior, and Posteroinferior. And you can see those there. In this case, we used a divider in the passport to help organize those. And then we will refer to those corresponding colors when we pass these links to help shuttle the graph to keep everything sorted out later in the case. Now we'll go to the back table to prep our allograft. So now we're on the back table. We have our template. And if you think of the three dimensions looking at it, the height was appropriate to this template. So that's what we're going to aim for on the allograft as was. Now that we've fine tuned it our A to p length, the width is something I'm keeping in mind. Speaker  And so anatomically This zone is where the segmental defect is. I'm going to come just a little bit anterior because it's a little thinner there, and I think more appropriately matches the size of our template in that zone. Now that we've got the appropriate size in all three dimensions, we'll pass all four of our links in corresponding fashion to the colors that we place them in our defect. So here's the final prepared allograft on the back table with our blue Anterosuperior black Anteroinferior white and blue Posterosuperior and white and black Posteroinferior links passed in luggage tag fashion. We'll now pass these of the corresponding colors in the knee. So now we're going to pass first our two posterior shuttle stitches to feed the posterior mini tape links that are in the graph that have been passed. And this will help pull the graft in. And I'm also going to push with a king fisher. So now what I'm going to do after we have it provisionally placed is Thai order in my opinion doesn't matter. I'm going to for this case do posterior first. So as you can see I'm tying the blue and black striped links together first. And then next we'll tie the anterior solid blue to solid black. So now we have our stability of the graft to the rim. Speaker  And then you can augment with all inside fiber stitch or inside out sutures and side to side fashion to stabilize the graft to the anterior native meniscus and the posterior. So now we're placing a 24 degree fiber stitch in the posterior aspect at the junction of the graft to native meniscus. So here is kind of the final product. You can see that we've added side to side anteriorly in this case with an all inside fiber stitch. This can also be done with an inside out, and this will nicely reduce the allograft to the anterior aspect of the native meniscus. We've done the same posteriorly to reduce the posterior aspect of the native meniscus to the allograft, and then we can cycle the knee gently there to check it. Post-operatively. What I'm currently doing is six weeks non-weight bearing on these. Similar to a meniscal allograft transplantation with a brace start PT immediately post op day one swelling minimization range of motion. Usually do 0 to 90 for two weeks, then advance as tolerated. Usually it's about a 1 to 2 week progression from non-weight bearing at week six. Goal would be about checking strength at three months, six months, then nine months if need be, with a 10% or less differential between the sides before return to sport.

Segmental Meniscal Allograft Transplantation Using the Segmental Meniscus Procedure Pack

At the Hand and Wrist Fellowship Forum, Daniel Koehler, MD (Dallas, TX), reviews indications, anatomy, portal placement, and technical pearls for carpometacarpal (CMC) and metacarpophalangeal (MCP) joint arthroscopy, supported by case-based illustrations.

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NanoNeedle™ Arthroscopy for Carpometacarpal (CMC) and Metacarpophalangeal (MCP) Joint Pathologies

OrthoPedia: NanoNeedle™ Arthroscopy for Carpometacarpal (CMC) and Metacarpophalangeal (MCP) Joint Pathologies

Donald Hohmann, MD (Dallas, TX), demonstrates the surgical technique for using an Arthrex bone void filler to augment the bone surrounding the lag screw within the Arthrex Trochanteric Nail System.

Technique Demonstration of the Arthrex Trochanteric Nail Biologic Augmentation System

Hello. My name is Doctor Donald Hohman from Dallas, Texas. And today I'm here to perform a surgical technique demonstration for Arthrex Trochanteric Nail Augmentation System. This system allows for a streamlined approach to deliver biologics to the femoral head in patients with poor bone quality during trochanteric nail implantation. The system is offered as a single use sterile kit and includes a 3.2mm delivery cannula, guide pin and three one cc syringes, and a female to female luer. The delivery cannula features a custom tip design of four slots, spaced equally to deliver biologics to the surrounding bone that the lag screw threads will contact. The cannula also features laser lines that correspond to all lag screw lengths for precise delivery of biologics. The kit also includes a 3.2mm guide pin that is longer than the current lag screw guide pin offerings to simplify the removal of the guide pin prior to inserting the delivery cannula. Finally, the three one cc syringes and female to female luer can be used to transfer the graft into a smaller size syringe and reduce the back pressure that can sometimes occur when dealing with larger syringe sizes with respect to biologic offerings. The system is designed to be compatible with any injectable graft material, but for the purpose of this demonstration, we will be using Quick-set calcium phosphate cement. Now let's walk through the steps to deliver biologics through the lag screw into the femoral head. Prior to beginning lag screw placement, it's important to use the 3.2mm pin offered in the augmentation kit to ensure you can grab and remove the pin once it comes time to replace it with the delivery cannula. If a shorter 3.2mm pin is used initially, it will need to be replaced with the longer pin. Following the initial ream at this junction, you can verify both your reaming depth with a simple measurement and both your lag screw length. I'm going to begin to ream. It is important to note during this step, if you perforate the femoral head, augmentation with cement should not be conducted due to the possibility for material migration into the joint space. You can also verify the femoral head has not been perforated by injecting a radiopaque dye through the delivery cannula prior to cement delivery. Now you can see we've created our pilot hole, and based on our measurements, we're going to use a 95mm lag screw. At this point we're going to begin placement of the lag screw. Now before fully setting the lag screw, it's important to note when planning to augment, you will want to stop advancing the lag screw about ten millimeters from your final placement or just past the metaphysis if you prefer going off an anatomic landmark. This will allow us to inject the biologic into the surrounding bone of the lag screw threads. So now we're about ten millimeters from our final location. You can see this longer guide pin protrudes from the handle, which allows us now to replace it with the delivery cannula. From this step, because we are using a 95mm lag screw, we're going to insert the delivery cannula until we reach the 95mm laser line on the cannula. This measurement tells you the appropriate injection depth with respect to the lag screw On our back table. We've already mixed the quickset and we're going to transfer the cement into the one CC syringes. Again, the purpose of this step is to minimize pressure associated with larger syringes. At this point you can also verify on fluoro the cannula is in the right location for delivery of the cement. By verifying all of the injection ports are past the tip of the lag screw. At this point, you can also adjust the depth of the delivery cannula if a different location is desired. Now that the cannula has been filled with the cement, we can use the inner trocar to deliver all of the cement. A couple fluoro images should be obtained as you are delivering the cement to verify the final location. If significant back pressure is felt when inserting the cement with the trocar, at that point no more cement is needed. Now that all of the cement has been delivered, we are going to advance our lag screw and the technique is complete.

Technique Demonstration of the Arthrex Trochanteric Nail Biologic Augmentation System

John Xerogeanes, MD (Atlanta, GA), performs an endoscopic quadriceps tendon defect closure using the QuadClose™ technique with 0.9 mm LoopLink™ SutureTape and a self-retrieving Scorpion™ suture passer.&nbsp;

Endoscopic Quadriceps Tendon Defect Closure Using the QuadClose™ Technique

Today we're going to introduce the suture tape loop link used for closing the defect in the quad tendon that you see after harvesting a quad tendon for ACL reconstruction. It can be used both open or endoscopically. It's a nine millimeter loop, the round circular needle on the end that you can cut off and also use with a scorpion needle. It can be used both in a running fashion or in an interrupted type suture fashion, whatever you deem is most appropriate. So now we're inside the knee endoscopically looking at where we harvested the quad tendon, you can see that there's a full thickness quad tendon harvest and you see a defect. You can see tendon on both sides. There's synovial tissue and articular cartilage. Down below you can see the VMO to the right side and over to the lateralis over here. So what we're going to do is close this. Now we close this because if you leave it open you're going to extravasate fluid when you're doing the surgery. Number one. Number two you can feel the defect and afterwards. And patients don't like that. And number three, if you put this together, you're going to get beautiful healing on the MRI, which you're not going to get if you don't put it together. Our plan is to use the suture tape loop link to do the closure. We'll put a luggage tag suture from here to here in the apex to pull this together. Then we're going to go and do a running suture just by alternating the scorpion we're going to come this direction upside down. Upside. Upside down. Upside. You'll see what I mean to pull this together nicely all the way down. This allows you to do this through a very small incision. And you get really good visualization that you wouldn't get if you're trying to look in a wound. We're going to use the suture tape loop link to close the defect in the quad tendon. We're going to do that endoscopically. So we don't need this nice curved needle here. So what we can do is hold it and cut this off. The beauty of the design here is that this is long. Let's say it gets frayed at the end. I can bring it here. Cut it again and you can do that multiple times. So this is very easy to load. Just take your scorpion, pop the tip of your scorpion through the loop, and then pull the loop on and we're ready to go. So it's just like this and you're ready to do the luggage tag. So here we have a full thickness defect. Even if this were partial thickness, a lot of times we close it just to avoid feeling the defect in a thinner person afterwards. So we want to put this first one at the apex. So you'll see I'll go down I'll catch this. Go over the top and see if we can pull this together. So we're going to get a bigger bite here about right here. And then pull this back. And so we pull that and you're nice and tight at the apex. And now we're going to put those two layers together. So now we're coming in with the scorpion again. Now I'm going to take the scorpion and turn it upside down. I'm going to go just distal to the other suture. You can see where it is. And then I'm going to pull this through and you'll see how it's going to make a nice mattress suture as we pull it through. Now we're going to reload the scorpion. We're going to come in again on this time. And we're going to take the Scorpion. Go underneath this area here, grab it and pull it towards you as you make sure you're getting a good bite and then pulling this underneath. And now watch how this comes together. When we pull it, you can see it's pretty nice. Perfect. And now we're going to come in and do the same thing and travel down. Now depending on the quality of tissue you don't necessarily need to put these at half centimeter intervals. You can go a centimeter apart and you're still going to get a really nice closure. We come in here, we go upside down. We come back through. And we're going to do the same thing to the other side. Now we're going to reach in again. Go up, pull through. And each time we do this, it's easier and easier to pull this together. So as when you're closing any long suture and you're using a technique like this, you got to make sure that you pay attention to where your suture is because you can easily lock it, which is not the end of the world, but you have to make sure that you want to do that. And you can see as we go farther down, it's easier and easier to close this. You can go a little bigger bite here and a little more distal. If you have a partial thickness closure, then it makes this part easier to do. And oftentimes we like to do that. So you can't feel the defect afterwards. So you can see the incision. And as we enter the wound you can see we have a really nice closure a watertight closure. Now you could still use the scorpion to do this, but because we're right in the wound, you can do the rest of this using the free needle and finish it quickly and be done. Because you can see right in the wound. We just took a free needle and then continued our running suture by throwing two more sutures. And if you pull on it, you see how it comes together perfectly. So now we're ready to close the distal end of the harvest site. One of the neat features of the suture tape loop link is that it's small. So we're going to tie a knot with this. We're going to be able to bury the knot. And we're not going to feel it like you would on a number two suture. So this is on a thin person or someone that doesn't have much fat. They're not going to feel this knot at all. So we take the scissors and we cut just one limb of this. Now for the final throw of the construct. We load the free needle, take a nice big bite of this tissue. This is really good tissue at the end. So it's a little bit difficult to pass. You got to be a little careful. And then you have two separate limbs. Now we pull this together and we can tie this off nicely for a water type closure. Again because it's so small you cannot feel this knot Afterwards and the not as you'll see it will bury right underneath. After we're done. And so you have a nice closure. Now you can cut your sutures and the knot is buried. So now we can look at the final closure. You can see it's a very nice closure for what was a big open wound. This is much easier if it's a partial thickness, but even on a big wound, this closes nicely. And there's really a low suture load and a low knot load. So you have several options here. One option is to close everything. But if you don't have time and you want to get going on your case, what we like to do is take the 4x4 and pack it. And then if there is any leakage, it's minimal and it's not going all over your case. Then at the end of the case, you take this out, you close it and you're able to go on to the next case.

Endoscopic Quadriceps Tendon Defect Closure Using the QuadClose™ Technique

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

Thomas Youm, MD (New York, NY), performs a core decompression for avascular necrosis (AVN) of the femoral head using the AVN expandable reamer and AlloSync™ Pure demineralized bone matrix (DBM).&nbsp;

Core Decompression of the Femoral Head Using the AVN Expandable Reamer and AlloSync™ Pure DBM

We are here today to show core decompression of the femoral head for avascular necrosis. The idea behind core decompression is to prevent eventual total hip replacement. We describe a technique that allows for seamless delivery of biologics and bone support into the core decompression tract. These are some examples on imaging of avascular necrosis of the femoral head. We have an x ray AP left hip showing avascular necrosis of the femoral head. Also MRIs both T1 and T2 views of the AVN of the femoral head. The indication for core decompression is to not have any subchondral collapse. In the presence of a crescent sign. You can see the crescent sign on the MRI images on both T1 and T2. We are here at the back table to show you the instrumentation for the core decompression set. We have both reusable and disposable instruments. The disposable instruments include A24 guide pin, A50 reamer, expandable reamer which is torque limited, as well as the application guide for the biologics. For the reusable guides, we have the drill guide with a handle drill guide insert, as well as a t-handle with a torque limiter. Critical part of core decompression is consideration of biologics. These are the biologics that I use. We have the Arthrex, BMA, vortex threaded needle Allison Pure. We have the Kwikset cement. What we do is with the BMA needle draw the bone marrow aspirate, mix it with the Allison Pure to fill the cavity of our core decompression to allow for healing. The quickset is then used to backfill to allow for to prevent leakage of the BMA. This specimen has been prepared with a flush fit cannula inside the joint. We're focusing on the open technique, but we will show arthroscopic pictures of the femoral head in preparation for our technique. I draw my landmarks. We see here is the ASIS with the iliac crest. I draw the inner and outer tables. I'm drawing the anterior femur, posterior femur and the tip, the greater trochanter. I use the Arthrex vortex needle to get my bone marrow concentrate. I do this early in my case so that the bone marrow concentrate is ready to be mixed with the allicin pure to share a pearl that I use to get my targeting and keep the incision small. I lay a guidewire right on top that you can use a 2.4 guidewire from the set. And I want to get my angle. If you can take a c-arm shot here. Another one? Another one. Right. And most lesions are anterior superior. So we'll mimic that in our demonstration today. We are going to draw a line right over the guidewire towards the femur. And that will give us an idea where we're going to start our incision. Next thing I'm going to do to see our starting point is I'm going to poke the guidewire or guide pin right on the femur if you can take a shot there. And another shot there to see on our starting point. So I like my starting point here. I'm also seeing the posterior aspect of the femur where we're going to start a little bit posterior on our incision. I can feel anteriorly, so I know I'm in a good spot. This is where I will center my incision. This will be my incision for our core decompression. So I have my drill guide right on the lateral cortex. And I'm bringing my guide pin right inside. Let's have a shot here. We have our guide pin in appropriate position. As you know, most femoral AVN lesions are anterior superior. You can see we're somewhat superior to the central portion of the femoral head. Now that we have our guide pin in appropriate position on the AP short of the articular surfaces, we're going to check a lateral view accurate targeting of our guide pin into the AVN lesion which is typically anther superior, is critical for this case, with multiple fine adjustments, we see on the lateral view of the hip that our guide pin is somewhat anterior from the center point, which is exactly where we want. Now that the pin is in good position, we are going to take out the drill sleeve and put the cannulated five millimeter reamer over the drill. As we get to the subchondral bone, the bone will feel stronger and more sclerotic. Shot, please. And it's important to make sure you're not engaging the guide pin in the reamer so as to not advance that guide. Pin through the cartilage. Shop, please. Shop, please. Right there. At this point, we're going to advance the stepped five millimeter, five millimeter drill sleeve using our slotted slap hammer. Shot there. Okay. So here we see that the step collar is flush with the cortex. And at this point the sleeve is appropriately inserted. So at this point we will take out the reamer first and then the guide pin. So this is the torque limiting expandable reamer just to show you how it works. This black knob here is to expand it from 6 to 18mm. So to prevent premature deployment of the blades inside the the bone, we hold it right behind the black knob. No pressure from posteriorly on the t-handle and we insert. And we'll confirm with C-arm to make sure that we're at the appropriate position and depth. It's important to note when you use this reamer and start expanding, go up one notch at a time. Have at least a few turns, and if you're feeling a lot of chatter, don't get. Don't prematurely advance too quickly. So here I'm at six millimetres. Turning over to nine. And this is at maximum expansion shot there please. One more time. Good. All right. So now that we're at 18mm, we want to check on the lateral view, which we did to confirm appropriate position. And here what I'm going to do now is I'm going to withdraw this back and still turn to get chatter so that we can create more decompression of that avian lesion. If you can take a calm shot, please. So as we pull this back and keep turning at 18mm, we're creating a larger cavity for filling of our allosyncarpia with bone marrow concentrate. Take a shot, please. And you can hear the chatter shot again please. Good. All right. So at this point I'm going to bring our reamer back down to six and we'll pull this out shot there. At this point with the reamer out, it's a good idea to flush out any necrotic bone and tissue. We use the applicator from our disposable set to insert. Take a shot, please. Calm. One more. Good. I'll remove the inserter at this point. Insert syringe with saline shot again, please. And we'll just flush it out under some pressure. Okay, so this is our 250 millimeter nanoscope needle. We're going to take a look inside our decompression tract and our tunnel to see if we got to the sclerotic bone and necrotic bone. Obviously in this cadaver model you won't see the necrotic bone, but you can see very clearly a very good resolution of the intraosseous space. At this point, we have five CCS of our Allison Pure with five CCS of bone marrow concentrate. I will mix this in a 1 to 1 ratio. I also have the quick set here ready to go. Once we are done with our Allison Pure mixture, we get the quick set ready for backfill preparation. We have our biologics applicator, which we're going to insert into our drill sleeve and we will confirm appropriate depth. I like to be right at the entry point of the cavity. Take a shot please. Good. Take a shot, please. So, right at the entry point of the cavity. I've taken my five cc slurry of bone marrow concentrate and allicin pure and transferred to one cc syringes, which we have here. These will secure themselves to our applicator, and we'll start injecting in the beginning. There's not much resistance because we're just filling our applicator. But once we remove once we insert our plunger, we'll start to see this mixture go into our decompression tract. So I recommend using the plunger slowly so as not to penetrate the articular surfaces in case there's any chondral fissuring. Yeah. X ray please. X ray please. Yeah. You can see filling. I'm getting a little bit of resistance here. I'm going to pull back our applicator x ray please. X ray please. All right. So we got nice filling there. Now what I'll do is just for the backfill for the quick set I'm going to retract our applicator back further x ray please. Right about that level. Okay. Now we have our quick set that's been transferred to a syringe for easy application. I'm going to insert that right into our applicator. And we're going to inject that in. All right good. We'll finish that in. And then we're putting the plunger in here to complete the insertion of the quick set and chat there. Good. Once we're in we'll take this out and we'll take our whole system out at this point. Shot again. Very good. So at this point the surgery is complete. We will have post-op images that will show on x ray. Our decompression tract filled with Kwikset as well as the bone marrow concentrate with Allison Pure, have an x ray view here. We'll also have an MRI view of the decompression showing filling over time. I also have a bilateral hip MRI where a patient has AVN on both hips. On the right hip, you can see there's still bone marrow edema from the AVN on the left hip. This MRI was done over a year after surgery. You can see complete bone healing and no evidence of any necrosis on both AP coronal as well as axial views. As you can see, the core decompression surgery we performed today was done under a minimally invasive technique with about a two centimeter incision. Appreciate you taking the time to watch our video today. Thank you.

Core Decompression of the Femoral Head Using the AVN Expandable Reamer and AlloSync™ Pure DBM

Erik Kubiak, MD (Las Vegas, NV), presents the Arthrex extra-articular distal humerus plate for distal ⅓ shaft fracture fixation. The Arthrex Elbow Plating System provides a comprehensive solution for distal humerus and olecranon fracture fixation, using next-generation KreuLock™ locking compression screws. Dr. Kubiak has positioned the patient using the ElbowLOC® arm positioning system.

Distal Humerus Shaft Fracture Fixation Using the Extra-Articular Plate From the Arthrex Elbow Plating System

So Eric Kubiak from Las Vegas, Nevada. Today we're going to demonstrate application of the extra articular humerus plate through a posterior approach to humerus. We'll go through some anatomy, show you the salient structure at risk, which is the radial nerve, and then go through plate length options. My preference is to do these operations without the tourniquet, for the reason being that the tourniquet tends to shorten the surgical field and puts the radial nerve, which is the structure, at risk, potentially tethered and stuck under the plate. So of the plates this is the shortest. This is the longest. Operating holes increase by two holes as we escalate the plate sizes. You can see for this specimen this person the longest plate would be too long. These plates are differentiated from the conventional periarticular distal humerus plates in that they're much thicker. They're A35 plate in stiffness. Whereas the conventional periarticular plates are thinner and less stiff. These are really meant to treat those hybrid fractures, which are a combination of a shaft meta diaphyseal injury, the distal humerus. I tend to use these plates more than I use the periarticular plates. I tend to fix most of these with a longer, stouter lateral plate and then the appropriate medial plate. The design concept here is that the shaft plate and the periarticular plate have very similar distal screw pattern. To address the periarticular fracture. This distal screw cluster can either use the three five screws or two seven screws. I tend to treat most of these fractures with a stout lateral plate and appropriate periarticular medial plate as necessary. The only difference in the distal screw pattern between the periarticular plate and the extra articular distal humerus plate is the addition of this cross tab, which would allow screw across the trochlea. Important features of a direct posterior approach to the humerus would be positioning. So most of the patients we're doing lateral over an arm holder. Other people do them prone over a similar arm holder with the elbow to be extended or flexed. The incision is centered over the center of the triceps for an extra articular injury or an extra articular humeral shaft fracture. I often don't need to develop the medial side of this approach. If you do not develop the medial side, I would say you have to be very careful of the ulnar nerve or trapping the ulnar nerve, which is just on the other side of the humerus. So retractor is placed under the triceps, can catch the ulnar nerve and inadvertently injure it when the patient triceps is immobilized out of the way. The easiest way to do this is in skin incision down on the fascia over the triceps. Open the triceps fascia, and then elevate the triceps off this overlying fascia. That'll allow you to find the cutaneous branch of the radial nerve, which then will take you to the radial nerve. When you're actually doing the live dissection, the vessels that travel with the radial nerve can be quite bloody. And so we use a bipolar cautery because you're cauterizing right around the nerve. And it's easier than using the pickups in the cautery. Electrocautery. The other thing I would say is, when you're doing this approach and you're mobilizing the radial nerve, make sure you get underneath of it and make sure you can get underneath of it proximally and distally. Most of the time when I'm doing this procedure, I'm demonstrating it. We go up all the way to the deltoid and, and come to the confluence of the two heads of the triceps and the deltoid. That kind of marks the top of this incision for me. Once I'm here, then I can track back. If you're having trouble finding the radial nerve, go to a place that's safe distally. Work proximally. Go to a safe place proximally. Work distally and find the nerve between the two approaches. That's a really easy way to get at it without getting in too much trouble. When you need to do that, most of the time it's because this is a fracture that's gone on to nonunion, and you're picking the nerve out of the nonunion ball. So in that circumstance, just come somewhere where you're safe proximately somewhere you're safe distally, and work until you find the radial nerve in between the two. One of the important points of humerus fractures is the humerus. Has some curve to it in the anterior posterior plane, or in the coronal plane, it has a radius of curvature. These plates also have a radius of curvature in that coronal plane. This particular patient has an extra kind of kink in the distal third of the humerus, where if this was broken, we'd probably just take the kink away and reduce it. Take this. But in this circumstance, we had to put a little bit of a bend in the plate to facilitate her anatomy. Again, the plate's going to come up under the radial nerve. Be fitted to the distal humerus and the shaft of the humerus. Be really careful of the radial nerve. Try not to wind it up in the drill bits, screws, etc. and then in the dictation we always dictate where the nerve passed over the plate. So in this circumstance we would say the nerve passed over the first proximal hole. Again true three five screws. So 2.5mm drill bit. By cortical. This should always in most human beings is going to be 26 to 28. So this is measuring 26. Titanium is really nice. Now the one thing I would say is in this circumstance where the pulling the apex into position tended to lift the one end of the plate or the other off. I would fix to the metastasis first, because that's going to be my dominant thing that I'm worried about. Fix the metastasis first and then draw the bone to the plate. Calibrated drill guide has two marks on the drill bit. The first mark is for the short side so up to 50mm. So as you can imagine we're at 15 and there's 15mm of drill bit extended exposed. If you come up to the second line drilling across the trochlea, the double mark starts at 55, 60, 65, 70. Drilling towards the coronoid. If you're really in the coronoid can be up to 30. Most of the time down here it's going to be 16 something like that. So we're at 26 here. So 2627. My preference is pin the plate. Conventional compression screws. And then if if locking screws or fixed angle screws are indicated A, i.e. secondary to bone quality. Then I would go to the fixed angle screws or locking screws. After I'd already put the cortical screws in place, you can see how the plate pulls really nice down the bone appropriate to the bone. Once that plate's appropriate to the bone. The other cortical screw. And you've got this like really, really perfect plate contour plate sitting against the humerus. Appropriate. So this would be the intermediate step of this procedure. You have the plate pinned to the bone fracture reduced plate pinned to the bone. And then the cortical screws pulling the bone plate construct so that it's appropriately fit. Now when you look from the lateral sort of at the lateral aspect of the humerus, you can see this really nice plate contour fitting the humerus appropriately address, you know, appropriate to the bow of the humerus and a really nice distal fit to the distal humerus, which is going to be important because there's not a lot of soft tissue on the and the distal aspect the lateral humerus. If you feel it, and people will feel that plate pretty easily. So the number one reason to take these plates out is that distal lateral prominence. And again that's why you got to be a little careful about the radial nerve because you'll be pulling these things out. So so we're here we're going to demonstrate the three five distal lock. So 2.5mm drill 2.5mm calibrated cannula. Same concept with the single mark marks the depth. When I place this screw, I don't try to go by cortical because I know it's going right for the coronoid and the radial head. So here we're. About 22 3.5mm locking screw. With the. Limiting torque limiting attachment which if you're going to place locking screws with power. I would always recommend using the torque limiter, and then you can come back and address them by hand at the end to make yourself feel better, but I would always use a torque limiter with power. You know, when we first pull the plate down, often we're using we're measuring a screw from a plate that's not on the bone. For me, I'm going to pull it down and don't change these screws, which are obviously long on the lateral. The distal screws obviously long. I would place the distal locking screw first before changing this screw and shortening it. If you don't do that then the plate can pull off the bone. You can lose the reduction. The goal in my life is to obtain the reduction, then maintain that reduction until the patient's healed. And nowhere along those lines sort of lose the reduction. So I don't want to lose reduction once I've sort of gotten the fixation started. So this screw will be shortened after the definitive locking screws are placed. Final plate bone construct demonstrating a typical pattern of fixation with multiple screws placed into the Capitellum them these screws for me. Fixed angle variable angle screws are helpful because I like divergent or convergent screws to to really maximize fixation in this distal metaphyseal bone. The distal fragment will also have a minimum of a cortical screw and a fixed angle screw to really lock in that lateral column. Again, we'll go through the typical spiral fracture of the distal humerus. The proximal shaft fragment needs a minimum of three points of fixation. That's going to be, in most intents and purposes, a cortical screw to help hold the plate bone construct where it needs, and then backed up by locking screws or fixed angle screws. At a minimum, I would say of two, but I like three is kind of the number that I'm going to shoot for. And again, the radial nerve crossing over the top of the plate and making sure that all the additional wires are put in, all that stuff's removed.

Distal Humerus Shaft Fracture Fixation Using the Extra-Articular Plate From the Arthrex Elbow Plating System

John Zvijac, MD (Miami, FL), demonstrates the use of the NanoNeedle™ scope 2.0 and the PassPort Button™ cannula with auxiliary lumen for Nano shoulder arthroscopy labral repairs.

Labral Repair Using the NanoNeedle™ Scope 2.0 and the PassPort Button™ Cannula With Auxiliary Lumen

Speaker  Hi, I'm John from Miami, Florida, and today we're showcasing a label repair technique using the Nanoneedle scope 2.0 and the accessory Lumen Passport. This setup allows for ultra minimally invasive access and enhanced maneuverability. We've already established our portals, and the accessory Lumen Passport is positioned to facilitate suture management and instrument passage. You'll see how this design improves efficiency and flexibility during the repair. Here is what the accessory Lumen Passport looks like. We have a center hole for instrumentation, and then there is an accessory lumen, which allows for passage of a multitude of micro instruments for suture management. Here we see the nanoneedle scope in the posterior shoulder portal and the accessory passport lumen anteriorly in a rotator cuff interval. A little pro tip the accessory portal. If you can leave this inferiorly or posteriorly, it makes it a little bit easier for suture management. It's not that big of a deal. You can always put it in any position, but that's a little pro tip to help as you're moving this along. You can see the soft tissue bankart lesion that's occurred. This is the labrum all the way down. And we're well past the 6:00 position to allow for bringing the capsule both superiorly and laterally onto the articular surface. The labrum often falls not only medially but inferiorly while you're doing these type of surgeries. Speaker  So it's important to free all of this up for proper mobilization and tensioning. We'll be repairing this labral tear with the 1.8mm knotless fiber tack anchor. This is being done through the central lumen of our passport. And now we're going to pass the suture retriever through the accessory portal in our passport. You can see it coming through, and we can easily pass our stitch with the use of a scorpion through our central portal. And now we're going to just easily shuttle our loop stitch through our center portal. And now we're ready for shuttling a repair stitch. Keeping very nice suture management, preventing entanglement of the stitches intra articularly. We're going to take this stitch out through our center hole to allow for final cutting of the stitch. Here we're using the flush cutter, and we can just bring this down to central portal. And we can cut our stitch flush. And we're ready for the next stitch. The repair is completed with precise suture placement and minimal disruption to the surrounding tissue. The accessory Lumen Passport enhances suture management and expands our instrument options for suture passing during a label repair. Combined with the Nanoneedle scope 2.0, we're moving closer to an ideal solution for the ultra minimally invasive arthroscopy.

Labral Repair Using the NanoNeedle™ Scope 2.0 and the PassPort Button™ Cannula With Auxiliary Lumen

At the Sports Medicine Fellowship Forum, Sommer Hammoud, MD, (Philadelphia, PA), reviews historical and modern indications, patient selection, and surgical techniques for primary ACL repair supported by current biomechanical data.

Current Concepts in ACL Repair

OrthoPedia: Current Concepts in ACL Repair

Lee Hunter, MD (Columbia, TN), provides an overview of the components of the ElbowLOC® arm positioning system and demonstrates the assembly and patient positioning in the supine suspended position. This comprehensive arm positioner supports elbow positioning in supine, lateral, and suspended supine positioning, and wrist traction for wrist arthroscopy.

Supine Suspended Elbow Positioning With the ElbowLOC® Arm Positioner

My name is Lee Hunter. I'm an upper extremity orthopedic surgeon with Tennessee Orthopaedic Alliance. And today we're going to take a look at the Arthrex elbow lock arm positioning system. This system is actually a 4 in 1 positioning system. The components of the system include the base support, which is what all the various assemblies are built off. It has a wrist support component. It has a supine arm positioner. It has a humeral support as well as a humeral collet. It has a distraction nut, a lateral position or support. It has a reducer distractor attachment. It has a traction bar. The wrist tower. The wrist tower, traction gauge and the wrist tower bar capture. The undersurface of the lid also displays the three primary assemblies of the various positioning systems. The system also comes with a disposable sterile field kits, which contain foam blocks that slide on the various components as well as a self-adherent wrap. The system also comes with a double armed finger traps for the wrist tower components, and they come in the various sizes small, medium, large and extra large. This is a supine, suspended positioner assembly. It starts with a base support which is applied just cephalad to the patient's shoulder. This is a supine positioner component and in this application it's rotated such that this locking pin is seated vertically. Then the supine positioner is loaded into the base support locked into position. Next, the wrist support component is applied over the distal arm of the supine positioner. The patient's hand is placed around the wrist support and stabilized with the self-adhering wrap contained within the field kits. This is the basic working position for supine suspended arthroscopy, with the elbow resting at a 90 degree angle. Elbow flexion extension angle is adjusted by raising and lowering the height of the supine position, by adjusting the locking knob on the interface of the base support.

Supine Suspended Elbow Positioning With the ElbowLOC® Arm Positioner

Kaitlin Neary, MD (Boise, ID), reviews the technique steps for using the Syndesmosis TightRope® PRO implant.

Technique Overview: Syndesmosis TightRope® PRO Implant System

Speaker  Hi all this is Doctor Caitlin Neary here to demonstrate the surgical technique steps for the Syndesmosis Tightrope Pro implant system. Every kit includes the implant itself, the instrumentation required to place the implant, and an optional universal button that's compatible with both medial and lateral tightrope suture buttons. Now, the kit includes a tapered drill guide to protect both the plate and the surrounding skin from the drill flutes. The next thing I do is identify the proper location for the tightrope. Ideally, this would be 0.5 to 1.5 centimetres above the ankle joint line about at the mid portion of the incisura if possible. And the goal is to remain parallel to the articular surface while you're drilling. Exiting somewhere around the central quadrant of the medial tibia. So you can see here the drill guide fits very nicely into the chosen hole. I want to insert the drill and have my hand parallel to the articular surface. And then you want to drop about 30 degrees posteriorly to have the proper center center trajectory across the Syndesmosis. Once you're happy with the placement and the trajectory of the drill, you can start drilling through all four cortices of the fibula and tibia. I take X-rays throughout the drilling process so I can change the trajectory if needed, and we keep going across the distal tibia until we reach the far cortex. Speaker  Now we're ready to place the tightrope Pro through the guide tunnel. With the Tightrope Pro, the drill tunnel has now been sized down from 3.7 to 3.2 millimetres. With a more narrow drill tunnel, you can now fit a lower profile implant with both medial and lateral buttons. Now being smaller with an improved anatomic contour giving a smaller footprint on the medial distal tibia and lateral fibula, the tightrope is inserted through the guide tunnel with the red tab pointed towards the foot, as you see here. You want to insert the tightrope all the way until the medial button has just passed the far cortex of the tibia. That's perfect. Another tip is during insertion. Make sure to push the device from the back with the pressure on the black tab. Once the tightrope has been inserted in the medial button, it's just past the far cortex of the tibia. Now you can pull and discard the red tab and pull the black switch to deploy the button medially. Once the medial button has been seated down onto the distal tibia, now it's time to bring the lateral button down to the lateral fibula. This is done through a self-centering mechanism using this black inner rod. Speaker  What you do is you hold the insertion handle with one hand and keep it stable. Pinch the black inner rod and slowly with opposing forces, pull back as you pull the black inner rod out. You can see the button will be approximated down onto the lateral fibula and centered within the fibula plate. If the medial button requires further setting onto the medial tibia. You can now pull axial traction on the handle to set the medial button. Once the medial and lateral buttons are set in proper position, now it's time to tension the tightrope. You do this by disconnecting the handle and it immediately turns into the two paddles. You then use opposing forces and tugs on the sutures to perform your final tensioning. If more force is required to seat the buttons, you can actually take the handles and roll them up to give yourself a shorter working length and improved strength with tensioning. Now that the tightrope has been placed and fully seated and tensioned, you can really see the improvements in the profile of both the medial and the lateral buttons, with improved contour over the medial tibia less hardware prominence, and the lateral button really sits nicely within the plate along the distal fibula.

Technique Overview: Syndesmosis TightRope® PRO Implant System

Sanj Kakar, MD (Rochester, MN), provides a surgical pearl for an automatic washout technique when fixating an intra-articular distal radius fracture using the NanoNeedle™ scope 2.0.

SpeedPearl: Automatic Wrist Washout Technique With the NanoNeedle™ Scope 2.0 

Speaker  When performing NanoNeedle fixation of a distal radius or intra articular fracture visualization may be impaired by hematoma within the joint. To overcome this, I utilize the automatic washout technique, which has a ten millilitres syringe placed onto the NanoNeedle, and the joint is lavaged with either a two millimetres Saber or a 3.5mm Torpedo shaver.

SpeedPearl: Automatic Wrist Washout Technique With the NanoNeedle™ Scope 2.0&nbsp;

John Christoforetti, MD (Bethesda, MD), reviews his use of the Postless Hip Distraction System (HDS), including tips for OR setup and patient safety, as well as the principles and science behind postless hip distraction and its potential patient benefits. Dr. Christoforetti also walks through each step of the setup and distraction process.

Successful Setup and Use of the Arthrex Hip Distraction System

Speaker  Hello, I'm John Cristoforetti from Bethesda, Maryland, United States. I'm here today to talk with you about advanced hip arthroscopy with the Arthrex HDS. We're going to go through some safety tips for experts who are looking to go to a post reduce, or particularly a post less performance of arthroscopy of the hip, to do everything that you can imagine without a post. When we start with our positioning, what our main main focus is on safety, patient safety and staff safety. We want to get through the day and we want to get through it well. And we want everybody to come out feeling better as a result of it. The patients have safety first priority with both post or post lists is a philosophy that has to be according to a whole team. That means the whole team has the responsibility to understand where our bed is touching the patient, how the bed is working, how we're protecting that patient at each step, the mechanics of how we balance the bed, and the proper way that a surgeon and anesthesiologist need to interface on making this case go safely. It really is the surgeon's responsibility to make sure the team is trained well and have that support available so the patient can go through either with a post post reduced or post method, a hip arthroscopic procedure that's going to keep them safe and get them coming back the way they want to come back. Speaker  This is the modern kit that we use. We've used this kit now for at least two years, and in using this kit, we have a pad that's available to protect our patient at the surface. And we have padded for the feet and ultimately a mobile limb spa setup that allows us to take the patient either with Post-loss post reduced or with the post augmented type of arthroscopy. The original experience with hip arthroscopy, with a dual vector, or with both an offset and a longitudinal distraction utilizing a perineal post where the foundations of our field. This allowed us to gain access to a deep space that we'd never really been to before. But as the early pioneers understood, putting that pressure in a concentrated way on the perineum could risk some injury both to the nerves of the perineum and to the skin associated with that contact pressure over rare but real complications. The learning curve of the international community moved towards some augmentations solutions, if you will, for post based access to the Hip, which the Arthrex HDS answers perfectly with a broadened, wide, perineal post to distribute the force across these tissues and with a breakaway option that allows that to be there for minimal, minimal opportunity to create this harm and also give you the benefit of both offset and longitudinal distraction with proven results. Speaker  But then there became the principle of how do we reduce that even further? We thought about how do we put pads onto the table, but also how do we take that padded post and break it away for the case portions that it really doesn't actually serve a purpose in particular, when we're into the peripheral compartment, when we have that post, it can get into the way and we're in the central compartment. We find that that post may help us. So we started with what's called post reduced hip arthroscopic surgery, and we move from the post in place. We move the patient all the way to the standard place on the post. We then create that readiness for distraction. But what we're doing is once the patient's in place, we break that pad and that post away, and we allow our traction to begin in a post free environment. One of the challenges with this type of technique is that you're planning to remove the post. So if you try to go back into traction after you've removed the post, it may not line up just right. So there were then potentially some benefits of going things post free from the beginning and staying there the whole way. Move forward by Doctor Madan. He was proposing to the rest of the world that maybe we could have less peroneal nerve palsy from the post. Speaker  Maybe less pain from the post may have engendered some pain. Maybe no skin injuries from the post, a more natural intraoperative physical examination and more room to maneuver through the case with the instruments. As the leg gets up and down into the peripheral compartment. These were some of the theories that started the world thinking about post free, hip arthroscopic surgery. And then we came to the modern post era, when we're trying to set things up safely inside the operating room for post lists. Here's a good image that demonstrates what I'm talking about, that we're using a standard or table with the Arthrex HDS. We're going to attach that onto a bed. One of the key pearls here is knowing how your bed specifically would attach to this table before the patients in there. And that goes back to training our teams. We then want to think about the balance of the table. The balance of the table in our operating room means we need to think about that long lever arm of the patient, plus the spa, and make sure the center of gravity of that patient is centered over the most stable portion of that bed. We are thinking about eventual Trendelenburg, but we want this bed to be stable in a parallel position to the ground. We then attach that semicircular pad onto the top of the bed, and we're ready to go. Speaker  When we begin to move our patient onto that post list table. We can think about getting them to move into the right position to begin with. These still images demonstrate what can occur if the patient moves a little bit higher up on the table, both with a post and without a post, and then what's going to have to happen if the tape, if the patient has moved over onto that table in a position a little bit higher to facilitate either the airway for the anesthesia team, or if a patient has long limbs that prevents their feet from resting onto the table extension, you may need to move them with a two person lift down into position. The image at the bottom of this slide demonstrates where that ideal position for posts. Distraction is marked out beautifully by the black semi-circular arc, and we're going to begin our case in that position. So once we've moved our patient onto the table and we've got them ready to go, now we've got to talk about securing the feet and then establishing the traction as we watch one of the main assets of the limb spar that we have is we can use gravity to make things easy, to even hook the feet into the table. We're going to unlock the foot rotation any time we slide the gross back up and down the spar, we're going to keep the spar in a slightly flexed position on the operative limb, and the nonoperative limb will be in a straight horizontal position. Speaker  When we unlock the gross and unlock the rotation, we can slide this back up and down the spar, putting the position of the patient into about a 45 degree flex position, allowing that rotation to be the last thing we tighten down. So the foot rests right inside the foot attachment. And then we can have a single person moving and getting that foot ready to be secure. Once our patient is positioned on the table and the table is right where we want it within the room, and we've confirmed we can gain Fluoroscopic access to view what we need to view. We're now ready to start sequencing the post list distraction. The patient is on the pad and we're starting with the operative limb first. What we're doing is placing that limb spar in about a five degree flexed position. We're then taking the slack out of the system with the gross attachment to the spar, locking that into place. Next, we move over to the non-operative side and we're going to move that same long traction, move out the spar, watching the anterior superior iliac spines move to a point where they are now parallel. Once we've received a parallel stop on our both limb distraction, we are now seated against the pad, and we know the patient is not sliding down the table, and we're ready to perform an air arthrogram to reduce the tension inside the hip even further. Speaker  And we're finding with nearly all hip constructs, this is something that now allows us to easily gain access to the interior of the joint. Now that we've got that patient positioned and secure on the pad, the limbs are set, our traction is set. We're ready to get started with our portals. Post arthroscopy will change the way your portals work. And not only that, the way your post list table is will change the way your portals are going to work. The shape of that portal pathway is going to either get thicker or smaller, longer or shorter. However you want to think about it based upon how the table is pressing the skin. So if you don't have a cutout on your post list table, you have a more of a square end. You're going to see that the tissues are lifted up and the lateral portals are elongated. When you have a post in place, you're going to see that those tissues are squeezed or compressed and the anterior portals are going to be longer. So there are two different changes that occur. A post where the limb is adducted against the post is going to squeeze or compress those anterior tissues, making the anterior portals relatively longer and a post less construct with a square end, which presses the soft tissues up, will now make those lateral portals longer. Speaker  In the best of both worlds, you have a cutout on the back of the table that allows the buttock to drop, giving you the free access to both the lateral and the anterior portals, and you'll find that in the post list technique. Those portals are actually the truest to patient natural size. One of the tips that we do focus on when we're going into the traction portion of the case is that we may stabilize the anterior superior iliac spine. On the operative side, as the micro distraction is applied. All of this is occurring after that first set of that patient on pad stable position is achieved. So in conclusion, the post list technique for advanced hip arthroscopy with the Arthrex HDS is a safe and effective way to succeed for your patients. Attention to safety, positioning and simple steps results in a reproducible procedure with a post list, post reduced or post assisted arthroscopy in the Arthrex system. Hopefully this tour through my journey from becoming a post to a post reduced to a post surgeon, has given you some encouragement that you can use this post technique both safely and effectively to perform advanced hip arthroscopy for your patients.

Successful Setup and Use of the Arthrex Hip Distraction System

Marc W. Gerdisch, MD (Indianapolis, IN), demonstrates his preferred thoracotomy closure technique with FiberTape® sternal closure using a dual-tensioner approach. He highlights the advantages of FiberTape Cerclage, noting its broad footprint helps reduce the risk of bone cut-through compared to traditional suture, while the enhanced closure method minimizes the potential for lung herniation.

FiberTape® Sternal Closure for Rib Approximation After Thoracotomy Incisions

I'm Mark Curtis. I'm chief of cardiothoracic surgery at Franciscan Health in Indianapolis. We're going to show you our method for using the fiber tapes for Rib approximation in any size thoracic incision. So for anyone who does thoracotomy surgery, whether that be lung surgery or minimally invasive valve surgery, no matter what size incision you make, if you make an incision in the intercostal space and you spread the ribs even a little bit, you are then vulnerable to lung herniation. So for folks who have been doing thoracotomy surgery of any variety for a long time, they've encountered a lung herniation at some point. So what we've been doing now is using the fiber tapes for our rib approximation for any thoracotomy. We do that as a figure of eight. We use the blunt tip needle, and we always start at the middle and work our way out. So in this case I'm going to use two figure of eights. And the first one will go here below this rib. And then the second is going to go a little bit farther medial. And we can really travel. We can cover the whole space of the incision. So one of the things that you'll notice of course, about the fiber tapes is they're considerably wider than the heavy suture that we would typically use. And that gives us a couple of things. It gives us the power to approximate those ribs as much as we choose. We don't want it too tight, but we want to bring them together. And then also because they're wider, they're much less likely to cut through the rib when you tighten them down. So we have the ability to be a little bit more vigorous with the tension on the closure than we would with suture, because it won't cut through or it's less likely to cut through. And also you're going to see that it's a titratable amount of tension so that we can really decide just how tight we want it and how close we want the ribs when we finish. So now we're finishing our figure of eight. We're going to come around. We started in the middle, worked our way out medially and again. This could be for any size incision. Then our final bite takes us back laterally to where we started. So take another tape and then again starting toward the center of the incision. We'll pack our first pass. Next bite is going to go way lateral out toward the end of the incision. Another lateral bite. And then we're going to finish in the middle again. So now we've got our fiber tapes in position. And we're going to go ahead and start to pass them through. So we can take all our retractors out. So we've passed the tail of the fiber tape through the little cinch knot that's built into it. And Then if we just want to take some of the slack out, we pull up on the one that's farther medial, the farther past that we did earlier of the same suture we pull up on that, we go back and forth a little bit and we get them close together. And again, same thing. Pull up here a little bit. We'll grab this side. We're work that down a little bit now. So now you can decide how you want to approximate this. We can do this by hand just by doing this. And the ribs have come together quite a bit already. So again here push that down. Pull this back so it can be done most of the time completely to close that way if you want to. But you can also go ahead and use the Titratable tensioner so that you can set the amount of tension that you're going to have on the sutures as you approximate the ribs. And I think this is the ideal way to do it, really, because it is more powerful if you tighten it all the way. So you have to be cautious Yeah, but it also is something you can do in small changes. So I tighten this a little bit. So the tensioner allows us to kind of titrate the amount of force that we're putting on there. We can feel the space between the ribs. We don't want the ribs right together because we don't want them to rub against each other. That can actually cause pain for the patient. And then you can have your assistant hold this one and then take the second tensioner. The fibertape is passed up from the tip of the tensioner. We aren't separating the tapes. There are two strands. The two strands go all the way up through the wheelhouse here. And then as I turn the handle, the wheelhouse turns and it closes the space. So now I can feel in there. I've got just about a finger breadth of separation there, and we're going to stop there. So and the different surgeons will want this, you know, different approximated differently with greater tension. But this is fine for us. We've got it nicely closed there, and then we release the tensioner and then we cut these strands. And we tie on top of our slipknot. So there's a slipknot that's built into it that's already there, that holds. So it's not moving. And then just in order to secure it, I'll put three knots on top of that and then we'll cut this one. So here I can feel and I have my gap here that I think is reasonable, which is just barely maybe the height of my, my index finger. And so the ribs aren't rubbing together, but there's also not a gap there that would pose a problem later. We put three knots on top of that and we cut both of those. And then that's our closure for the inner space.

FiberTape® Sternal Closure for Rib Approximation After Thoracotomy Incisions

Katherine J. Coyner, MD (Farmington, CT), demonstrates how to use the SurgeonVault® surgeon-patient communication tool to effectively manage cases, annotate images, and send patient reports.

SurgeonVault® System Demonstration

Speaker  Hi, I'm Doctor Kathy Coyne, a professor from UConn health. I want to show you today how I use the Arthrex surgeon vault in combination with the Synergy Vision Imaging system to communicate with my patients after surgery. From a practical standpoint, what works really well for me is how streamlined this process is. I can export the case media wirelessly from the O.R. tower directly to my iPad, and often have the patients post op report created before I even leave the operating room. That report includes intraoperative images and video, as well as a brief video explanation of the case from me. The rehab protocol specific to that patient all combined into one secure digital report. The first thing I'll do is I'll find the QR code. I'll then link that to my iPad. It'll then ask me to join the network. I'll join that. It's now pairing from the tower to the iPad. Once it's paired, I will then hit export on the tower screen. I will go to my iPad and you can see that they're now being sent over. I then disconnect and then I'll be able to access the case media. Once I'm ready to create the patient report, I log into the Surgeon Vault app and pull up the case. Speaker  I then pull up the template that I want to use for this particular case. This was a meniscus root repair. This automatically organizes all the images and video in the way I like to present them. Here is a little personalized message to the patient. Exactly what was performed. I can also create what's called a surgeon video. I just want to let you know that surgery went great. I'm getting ready to go talk to your family, but I wanted you to know that we were able to repair your meniscal root. There's a procedure overview about the specific parts of the case. If it was something unique that you also want to add, just go to the library where you can easily add procedures or aspects of a case, and that will add it into your own template. I can link specific PT protocols, and this is where I find it to be really helpful for them to be able to share this with their physical therapist. So we're all working off the same information. So then if I go back up to the case media here, there's a lot of options from this screen where I get to the annotation part of this. Speaker  And on the left hand side you can see all the different annotations. But most easily I can just draw an arrow and you have these pre-populated labels where I can then choose what to annotate. I can flip between images and videos extremely easily. I can see what my initial meniscus tear looked like, and be able to explain that to the patient very easily. And then ultimately, when I feel that everything is annotated appropriately and I'm comfortable with how everything looks, I come back to this screen and I'm ready to send this report and everything will get embedded into a secured email for me. Surgeon vault is far more practical and secure than sending patients home with paper printouts that are often misplaced or never reviewed. I can tell when the patient actually has already opened their report. It really has unlimited cloud based storage, and for me, it creates this powerful, organized library that I can use for teaching files, as well as really high quality presentations. Overall, integrating Surgeon Vault with the Synergy Vision system has really made my postoperative workflow much more efficient and really has improved how I communicate with patients. Thanks for watching this video.

SurgeonVault® System Demonstration

At the Sports Medicine Fellows Forum, Travis J. Dekker, MD (Colorado Springs, CO), reviews a practical, step-by-step approach to primary shoulder arthroplasty, emphasizing preoperative planning, team communication, and operating room setup to improve surgeon confidence, efficiency, and clinical outcomes.

What's NewAUG 24

Segmental Meniscal Allograft Transplantation Using the Segmental Meniscus Procedure Pack

What’s New This Week and Prior

AUG 22

OrthoPedia: NanoNeedle™ Arthroscopy for Carpometacarpal (CMC) and Metacarpophalangeal (MCP) Joint Pathologies

AUG 21

Technique Demonstration of the Arthrex Trochanteric Nail Biologic Augmentation System

AUG 20

Endoscopic Quadriceps Tendon Defect Closure Using the QuadClose™ Technique

AUG 19

Hip DiamondCut™ Burr

Procedure

Product

Medical Education

Corporate

Resources

Patient

Careers

What's NewAUG 24

Segmental Meniscal Allograft Transplantation Using the Segmental Meniscus Procedure Pack

What’s New This Week and Prior

AUG 22

OrthoPedia: NanoNeedle™ Arthroscopy for Carpometacarpal (CMC) and Metacarpophalangeal (MCP) Joint Pathologies

AUG 21

Technique Demonstration of the Arthrex Trochanteric Nail Biologic Augmentation System

AUG 20

Endoscopic Quadriceps Tendon Defect Closure Using the QuadClose™ Technique

AUG 19

Hip DiamondCut™ Burr

NanoNeedle™ Scope 2.0 Gains National Spotlight Through

Star MLB Pitcher's Recovery

Procedure

Procedure

Product

Product

Medical Education

Medical Education

Corporate

Corporate

Resources

Resources

Patient

Patient

Careers

Careers