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Michael A. Gallizzi, MD (Vail, CO), describes the importance of careful dissection of the scar tissue left over from multiple radiofrequency ablations (RFAs). Slow hemostasis is key when dissecting through the scar tissue.

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SpeedPearl: Endoscopic Approach for Revision Medial Branch Nerve Transection

When performing the approach for a revision. Medial branch transection. It is really important to identify the anatomy. The first thing you're going to notice is there's an entire wall of scar that is present over the lateral aspect of the facet joint, covering the transverse process. So during this, it's really important to perform slow hemostasis of all the areas that could be bleeding due to the previous radiofrequency ablation. This causes a significant amount of scar tissue around the medial branch, all the way from the mammillary process to the lateral wall of the facet, the cranial and caudal edge of that transverse process. So when you're doing your approach, it's very important to start identifying these landmarks slowly dissecting through that soft tissue, because you never know if there's going to be a bleeder or the medial branch itself underneath that large wall of scar. So in this video, we're looking at this entire scar ball that's formed from repetitive rfas. And this is why we believe that the medial branch transection is a more effective procedure in general, because we're doing a surgical and precise removal of the medial branch instead of ablating and scarring up this entire area.

SpeedPearl: Endoscopic Approach for Revision Medial Branch Nerve Transection

The All-Onlay MPFL Kit includes everything needed to complete MPFL reconstruction procedures, including three Hybrid Knee FiberTak® anchors and a ratcheting guide to stabilize the patella while drilling and implanting anchors.

All-Onlay MPFL Reconstruction Using Hybrid Knee FiberTak® Anchors

Hybrid knee fiber anchors feature one pre converted tension knotless suture tape loop and one sliding 1.3mm suture tape with swaged needles. The all online Mpfl kit features three hybrid knee fiber anchors on tapered non self punching inserters for easy anchor implantation, and an included ratcheting guide. The knee fiber tack ratcheting guide stabilizes the patella while drilling the pilot hole and implanting the anchor. To begin the technique. Make a two centimetres skin incision from the superomedial corner, extending to the center of the medial edge of the patella. Create a groove on the medial patellar edge using a rongeur or powered burr. Place the spike of the knee fiber tack ratcheting guide firmly on the lateral rim of the patella, and slide the ratcheting drill sleeve down to the medial rim of the patella. Create a pilot hole for the anchor by advancing the 2.8mm hard bone knee fiber tack. Drill until it bottoms out against the back of the drill sleeve. Insert the hybrid knee fibrotic anchor by hand, advancing the tip of the anchor until it is within the pilot hole. Using a mallet, gently advance the inserter until the inserter handle bottoms out against the back of the drill sleeve. Remove the anchor inserter and ratcheting guide. Gently pull the black suture limbs to set the anchor in the patella. Repeat the drilling, insertion, and setting process to place a second anchor, spaced approximately 15mm to 20mm from the first anchor. Pass the prepared graft through the blue knotless loops of both anchors. Tension the graft down to the medial patella by pulling the blue tensioning strands. If using the fluoroscopic template, place the template on the area of the medial epicondyle on the distal femur. Provisionally advance a 2.4mm zebra pin into the femur to a depth of approximately two centimetres, and at the trajectory of the intended anchor placement. Remove the template and create a small medial incision where the pin enters the skin. Slide the drill sleeve from the ratcheting guide down the guide pin and hold it in place on the bone. Remove the zebra pin while maintaining the trajectory of the drill guide sleeve. Advance the knee fibrotic drill until the hub bottoms out against the top of the drill sleeve. Insert the hybrid knee fibrotic anchor by hand, advancing the tip of the anchor until it is within the pilot hole. Using a mallet, gently advance the inserter until the handle bottoms out against the back of the drill sleeve. Insert a curved clamp down to the medial epicondyle and turn the tip of the clamp toward the skin. Using the clamp, pass the looped end of the fiber snare suture back to the patellar insertion area. Loop the whip stitched graft ends through the loop of the fiber. Snare suture and pass the suture from the patellar origin to the insertion point at the medial femoral epicondyle, deliver the sutures out of the medial incision, and pull the graft down to the medial epicondyle. Load the graft sutures through the blue knotless tensioning loop of the anchor with the knee in 30 degrees of flexion. Pull the blue tensioning suture of the femoral anchor to provisionally fixate both limbs of the graft. Take the knee to full extension and, using the attached curved needle, pass the black 1.3mm sliding suture. Tape limb from the anchor through both limbs of the graft. Tie the suture limbs and amputate the excess graft. The black 1.3mm sliding suture tape. Limbs with swaged needles from the patellar anchors provide added versatility and can be used to close the retinaculum, pass through the graft for additional fixation, or to accomplish a VMO advancement as needed.

All-Onlay MPFL Reconstruction Using Hybrid Knee FiberTak® Anchors

This animation demonstrates the use of ArthroCell™ Plus viable bone matrix for spine fusion procedures.

ArthroCell™ Plus Viable Bone Matrix for Spine Fusions

Speaker  Arthur Sell is a viable multiple cellular allograft that is intended for use as a nonimmunogenic cellular bone matrix for bone repair. When combined with the Arthrex graft, gun delivery of the Arthur cell into the disc space is simplified. Once the graft gun is appropriately positioned, actuate the trigger to begin deploying the Arthur cell into the disc space. Arthur Cell provides the three key elements necessary for bone repair osteogenic cells, and an Osteoconductive scaffold with Osteoinductive potential. The Osteogenic components of Arthur Cell include viable mesenchymal stem cells and osteoprogenitor cells. Arthur Cell also contains a blend of microparticulate bone, including a demineralized cortical and cancellous matrix that serves as an osteoconductive scaffold. Osteoinductive growth factors from the scaffold and the defect environment send signals to initiate osteogenic activity that supplements the patient's innate healing processes. Arthur Cell is an alternative to autograft and is intended for use in bone remodeling and repair of bony defects, fusions, and nonunion orthopedic applications.

ArthroCell™ Plus Viable Bone Matrix for Spine Fusions

Elizabeth G. Matzkin, MD (Boston, MA), demonstrates an ACL reconstruction using a GraftLink® construct with RT TightRope® SB implant with FiberTape® suture for the InternalBrace™ technique.
The InternalBrace surgical technique is intended only to augment the primary repair/reconstruction by expanding the area of tissue approximation during the healing period and is not intended as a replacement for the native ligament. The InternalBrace technique is for use during soft tissue-to-bone fixation procedures and is not cleared for bone-to-bone fixation.

GraftLink® ACL Reconstruction Using the TightRope® SB Implant for the InternalBrace™ Technique

Hello, I'm Elizabeth Matzkin from Boston, Massachusetts, and today we will be demonstrating an ACL graft reconstruction with internal brace technique and the new tightrope SB. As you can see here, we have our graft out on the table on our Graph Pro ready to go. We have a hamstring semitendinosus that's been quadrupled using a standard grafting technique. And we have our new tightrope SB on both sides of the graft you can see the yellow suture which is the soft button. This is just like our tightropes we've been using for the last ten years, but there's no metal. So for patients that may have metal adversity or a metal allergy, this is going to be perfect. There's also some other advantages to using the soft button, which you will see in our demonstration on our tightrope SB. You can see our blue passing sutures, our white tensioning sutures, our internal brace sutures, and these sutures which are used for elongating, which you will see as we pass the button into the knee for our ACL reconstruction. On the tibial side of our graft, we can see our blue passing sutures. These suture tapes here in the middle are from our graft prep. So there are saved sutures. We can see our white tensioning sutures. And then again, we can see the suture that we're going to use for elongating the suture button when we pass it into the knee. So we have about a 30 millimeter femoral tunnel. So we've marked 30mm from the end of this soft button. I also like to mark my graft around 15 to 20mm. It's often where we have these sutures wrapped around the graft itself. But that will help us as we pull the graft into our tunnel. And we'll mark it also on our tibial side. So here we are. We're in our right knee. We've already prepped our femoral and tibial tunnels. We have sutures passed through them so we can get ready to pass our graph with the new tightrope SB. So we're going to pass this through our suture here on the outside. And then we're going to shuttle our white tensioning sutures and our blue passing sutures through the knee here. As you're doing this, you're going to have one hand pulling through the sutures through the femoral tunnel and your other hand holding on to the the graft. And the extra suture in order to feel the tension as the graft is passing, as we're getting ready to pass our tightrope, SB, we have one hand holding our tensioning and passing sutures and our other hand holding the trailing sutures. This allows us to keep the tightrope sb lengthened as we pass this through. We've also switched our scope to the 70 degree so we can watch this go up our femoral tunnel. So again we're holding both ends of the tightrope. We're watching it up the tunnel. We can see it just passed through and we could feel it flip right there. And the other thing we can look at is we can see our mark that we made. On the sutures, which is also a second way to check that we're at the same length to flip that tightrope. Sb now, to deploy our tightrope SB we can either pull on the implant or pull on the internal brace, as you can see here and now, if I go to pull on my graft, you can see that tightrope is flipped and it's not going anywhere. One nice advantage of the tightrope SB is that once we've flipped it, if we're not happy, or for some reason, we've flipped it on the outside of the Iliotibial band, we can actually elongate it and flip it by pulling tension on both sides of the suture, and we can watch it unfold and we can see we can pull it back down our tunnel and we can start all over. So this is a very nice advantage, which we can't do with our metal tightropes. And you can watch this go flip one more time again, holding both sides of the tightrope. Now that our tightrope SB is flipped on our lateral femoral cortex, we're going to shuttle our graft up into the knee. We'll watch it kind of go up into our femoral tunnel. And here comes our beautiful hamstring. Quadrupled graft link. And see our internal brace here. So graph going into our femoral tunnel we have marked it at 15 to 20mm. So we know how far to pull it in okay. So we have our graph passing to our femoral tunnel. Now we're going to pass it into our tibial tunnel. As you can see here. We're going to keep our tiger trailing sutures outside of the passing suture. We're going to send these down our tibial tunnel. We'll pull some of the slack out of our internal brace suture. And again, we've left behind our trailing suture because that's what allows us to pass our soft button in an elongated fashion. We can remove our femoral trailing suture at this point, because that side has already been docked, and we will hold some tension on our tibial trailing suture as we reduce the graft into the tibial tunnel. Now that our tightrope SB is outside of our tibia, we can remove our tiger trailing suture and our blue passing suture. Now we're ready to tension this inner tibial tunnel. So I have a small hemostat here to take some of the tension off our tightrope, SB, as we provisionally take some of the slack out of it so it doesn't bunch up too much. It'll allow it to lay a little bit more flat when we get down to our tibial bone. Now you can actually put a little pressure on that button and kind of flatten it or pancake it out on the tibial bone. So it lays a little bit flatter as we completely deploy it. And our final tensioning. So now we are going to fix our save sutures from our graph prep, along with the internal brace in our 4.75mm swivel lock anchor. So we have our swivel lock in that has fixed our saved sutures from our graft as well as our internal brace, and we can cut those and then we can still retension our tightrope SB on both the tibial and femoral sides to complete the procedure. So here's our final construct. We have our graph link ACL with tightrope SBS on both our femoral and tibial side with an internal brace technique.

GraftLink® ACL Reconstruction Using the TightRope® SB Implant for the InternalBrace™ Technique

At the Orthopedic Technology and Innovation Forum (OTIF), John D. Adams, MD (Greenville, SC), reviews the latest literature highlighting trends in the surgical management of intertrochanteric fractures and the associated clinical outcomes.

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Intertrochanteric Fractures: Literature Review on the Management of Intertrochanteric Fractures

OrthoPedia: Intertrochanteric Fractures: Literature Review on the Management of Intertrochanteric Fractures

The Synergy exoscope is an autoclavable and reusable 0° 4K scope used to provide real-time visible light and near-infrared (NIR) fluorescence imaging during open surgical procedures.

Synergy Exoscope Imaging

Synergy Exoscope Imaging

Daniel A. Worrel, MD (Dallas, TX), discusses his transition to using a knotless soft anchor. During this cadaveric demonstration, he showcases the unique tensionable technology of Knotless FiberTak® soft anchors. Dr. Worrel describes the importance of restoring equal tension across the glenohumeral ligaments. With its small footprint, the Knotless FiberTak anchor allows for more points of fixation across the final repair.

Knotless FiberTak® Anchor: Evolution From Knotted to Knotless

Hello, my name is Daniel Worrall. I am here today to discuss treatment of instability of the shoulder. As I've converted to a knotless anchor. It has provided some additional benefits with regards to obtaining a very strong and stable repair and restoring the stability of the shoulder. We're going to put some anchors in today and we'll demonstrate some of these benefits. So we're here today with a right shoulder specimen that has a pretty typical anteroinferior labral tear off camera. We have placed a single anchor at the 6:00 position to begin our repair. We've already passed the repair suture, which is the blue suture that I've already grabbed. And you can see our our shuttling suture has a tape on one end which I've not grabbed, and a more tubular at the other end to identify it. And then we're going to grab both of these to make sure that they're not overlapping each other. And we will then shuttle the repair suture. You see, I've shuttled my repair suture through my shuttling suture here. And now what we're going to do, there's a little line to mark the appropriate amount of suture that you're going to capture. And then I'm just going to guide it through. And now retrieve it out my single anterior cannula. And one of the additional benefits that I've appreciated is, is that you get a gradual progressive tension as you will pull the labrum forward onto the glenoid rim. I've spent more time than I would like to think about, being careful about the direction at which I tie, so that I did not leave any knots that would abrade the articular cartilage. And this is dramatically simplified that portion of the process. This first anchor is generally to tack it to give us some soft tissue tension as we continue with our repair and capsular graphy. So here we are with our final repair. We've placed five anchors along the anterior glenoid, and we've got an excellent repair of our glenohumeral ligaments. And we've got a nice bumper here. The glenoid rim I was able to dial in the repair and the tension on these anchors without over constraining them. There's no concern for not migration or abrasive wear. I've been very pleased with this, with these knotless anchors, and would encourage you to consider it for your future repairs.

Knotless FiberTak® Anchor: Evolution From Knotted to Knotless

The Arthrex Elbow Fracture Plating System provides a comprehensive portfolio of distal humerus and olecranon plates. Designed to treat all fractures, the set comes with KreuLock™ locking compression screws, allowing the surgeon to both reduce the plate to bone and compress across a fracture. The plating portfolio is perfectly complemented by Arthrex soft- tissue procedures and fracture reduction, including LUCL/MUCL InternalBrace™ ligament augmentation, FiberTape® cerclage, and the ElbowLOC® elbow positioner.
The InternalBrace surgical technique is intended only to augment the primary repair/reconstruction by expanding the area of tissue approximation during the healing period and is not intended as a replacement for the native ligament. The InternalBrace technique is for use during soft tissue-to-bone fixation procedures and is not cleared for bone-to-bone fixation.

The Arthrex Elbow Fracture Plating System

The Arthrex Elbow Fracture Plating System

Patrick C. McCulloch, MD (Houston, TX), shares his experience with the Arthrex proximal humeral fracture solutions and how he decides treatment for patients along the continuum of care.

Dr. Patrick C. McCulloch Surgeon Testimonial: The Arthrex Proximal Humeral Fracture Systems Portfolio

Speaker  So if we have a younger patient who's involved in overhead sports, say they play tennis, then we may work hard to do an orif of approximately humerus fracture. If there are elements about that fracture pattern, poor bone quality, an older patient, a lower demand patient, then that's going to move towards a reverse shoulder arthroplasty with a more reliably good outcome. Stem geometry is important in reverse for fracture cases, having a rectangular one with smaller shoulders can help to get you some rotational stability. If you've got enough metaphyseal bone there and not having that too thick proximally so that you can actually do your tuberosity repairs is a nice feature of a reverse stem for fracture.

Dr. Patrick C. McCulloch Surgeon Testimonial: The Arthrex Proximal Humeral Fracture Systems Portfolio

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

Arthrex Variable-Angle Proximal Tibial Plating System

Arthrex Variable-Angle Proximal Tibial Plating System

Julie Bishop, MD (Columbus, OH), demonstrates the innovative bone block cerclage surgical technique for securing a distal tibia allograft to the anterior glenoid for treatment of critical glenoid bone loss. This subscapularis-sparing arthroscopic cadaveric demonstration shows the procedural steps and technical pearls for safe and reproducible metal-free fixation of the bone graft using interconnected FiberTape® cerclage sutures.

Bone Block Cerclage With Distal Tibia Allograft Surgical Technique

Bone Block Cerclage With Distal Tibia Allograft Surgical Technique

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

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

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

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

Christopher Adams, MD (Naples, FL), and Misty Suri, MD (New Orleans, LA), demonstrate the technique and order of operations for combining a rotator cable reconstruction with a biologic tuberoplasty to treat massive irreparable rotator cuff tears. They briefly review the demographics of a surgical candidate for this combined procedure.

Posterosuperior Rotator Cuff Tears: Rotator Cable Reconstruction With Biologic Tuberoplasty

Hello, my name is Chris Adams and I'm with Misty Surrey. And today we're going to demonstrate the technique for combining a cable reconstruction with a biologic tuboplasty for the treatment of massive, irreparable rotator cuff tears. Now we consider cable reconstructions in patients who desire an attempt at fixing their native rotator cuff, has significant comorbidities, or do not want a reverse shoulder replacement. Misty, what about biologic tuboplasty? Well, Chris Tuboplasty is also reserved for massive, irreparable rotator cuff tears, but we specifically seek patients who are painful but have preserved range of motion. We prefer those with Hamada 1 or 2 without any arthritis. They need an intact or repairable subscap and can't have any pseudoparalysis or external rotation lag. The beauty of these two techniques is that they can be done together without adding significant surgical time, or burning any bridges for the future. I agree, but people often ask when would you combine them? Well, we start with the biologic tuboplasty patient with no arthritis. Hamada 1 or 2 with preserved motion. Who desires pain relief? The purpose of adding a cable reconstruction is to improve the kinematics of the shoulder, and to potentially improve the patient's strength and function, and to preserve their native shoulder for as long as possible. Now let's see how it's done. So you can see here we have a right shoulder glenoid on the left humeral head on the right. We see that we have an irreparable rotator cuff tear. If we pull over, you can see that it's just too much tension to pull the rotator cuff back to the articular margin right there. So we're going to be performing a cable reconstruction. So we're going to start with a long tape loaded up on a scorpion. We're going to come through our lateral portal. We're going to first go far posterior and lateral as we can. We're doing a figure of eight pass through the posterior rotator cuff I like to start posterior. And then I'll work my way from posterior to anterior. So we've already determined that in terms of the posterior anterior, if we put it back here, it wouldn't tension enough. If we put it up here it would tension it too much. So this is the spot right here that we're going for. We're going to punch down to the swivel lock or SL level. So if you notice here that we've placed this anchor where right along the articular margin here, half on, half off. And the reason why is because we want that graph to be flush with the articular margin when we're done. So now we're going to slide in here. We're going to place the anchor in there. We're going to make sure that we don't over tension it. That's just the right amount of tension that we have right here. And so we're going to go down and we're going to dunk it into the pilot hole here. So you notice here we're inserting a knotless swivel to secure that fibertape suture on the outside. You may notice here that when we pull this anchor back we're going to keep these sutures for the biologic tuboplasty. So we're not going to cut them. However we are going to cut the shorter limb of the fibertape with the fibertape cutter. We're just going to cut the short limb here. We're going to leave the long limb. So that's out of the picture now. So if you notice here we have the sutures from the knotless mechanism that we're going to later incorporate into the biologic Tuboplasty. And then here we have the long fiber tape that we're going to pull out the lateral portal. So now through the lateral portal you're going to see us every single time we're going to come in here. And we're going to pass the sutures right next to each other. So we come right here. This would be the next one. Now we apply tension every time we pass it through. Now the beauty of this technique is, since it's all going through the lateral cannula, through that lateral portal, you'll see that we don't need any special grasping tools to grab the suture each time. All we're going to do every time is just keep pulling it out the portal, and then we're just going to tension it each time. So, Chris, how much of a gap should there be between each bite of your cable reconstruction? So if you notice here we have the scorpion. Now the width of the scorpion is about four millimeters. And we want each bite to be about 3 to 5mm from each other. So if you just use this as a reference guide we can say okay, all I need to do is just move it over to right here. And then I know that is a good position for it. Good passing of the suture. So you can use the scorpion and it gives you you notice how we're about 3 to 5mm between each pass. And in terms of mediolateral, how medial do you go with your bite for the cable reconstruction. Yeah. So one of the things and again pointing out that this is a cadaveric demonstration. So we're going to get into the muscle a little bit. And that's okay for this demonstration. But when we're talking about a live patient we want to keep these passes within the tendon substance. And if you have no tendon then you just go into the muscle. Yes. Yeah. Yeah. That's exactly right. So if you notice, we've passed it several times through this lateral edge of the cuff. Now we're going to be going in for the final pass in the very front here. So we're right where we want to be placing that anchor. So I'm going to come down here. And this is going to be the final pass. Come back. And so now you can see that we are all the way from posterior all the way to anterior passing again about 3 to 5mm between each pass. And we tensioned every time we passed it through that lateral edge of the rotator cuff. Now, what we want to do is take that kingfisher again and we want to say, okay, where do we want to place this anterior anchor. So right here again we want to be looking at this to find the ideal placement. I think in this case it's going to lay right there. That's we want to place the anchor right there and again right along the articular margin. Because we know we're going to be performing a biologic tuboplasty afterwards. So we want that half on half off, just teetering right on the edge of that articular margin. So now what we're going to do is pull the suture out of the portal that we are going to be placing the anchor. So we're going to grab it, pull it right out of here. And then we're going to insert the punch back in here through this anteriolateral portal. And that articular margin half on, half off placing the anchor. And they're going down to the swivel lock or the SL level. Secure this knotless swivel lock anchor in the anterior aspect of the articular margin to complete the cable reconstruction, or to make sure that we're all the way down. Maybe just another half a turn to make sure that we're all the way down. And again, we're going to keep those sutures for the biologic tuboplasty. Now, what I'm going to do is cut the tape that we just passed. Now we're looking through the lateral portal and you can see the cable reconstruction. You can see that suspension bridge that was created with both the posterior and anterior attachments. And then again we have the sutures from the knotless mechanism for when we want to incorporate a biologic tuboplasty into this surgery. After the cable reconstruction with internal external rotation, the rotator cuff is moving as a unit. Now that we've completed the cable reconstruction, Misty is now going to demonstrate the biologic tuboplasty. So for the biologic tuboplasty, we'll switch out the lateral passport cannula from the eight to the 12. For better suture management. We'll insert a passport divider into our passport cannula. We've measured our distance between our anchors. So between our posterior anchor here and our anterior anchor. And we've measured that to be 25mm. The graft will stretch by approximately 10 to 20%. So we'll downsize our graph to 20mm in the posterior to anterior direction, and then the medial to lateral direction. We've measured 20mm. Here we have our towel here our standard blue towel that we place here on the skin where we're going to rest our graft. So in terms of orientation of our graft we place it on our towel. And in our medial aspect of our graph, we have the loop stitch on the undersurface of the graft on both sides. So that will be posterior and anterior. And then we have our two luggage tags on the lateral aspect of the graft placed in each corner. So Misty, how do you decide what graft thickness to choose? Well, typically, Chris, I use a 3 millimeter or 4 millimeter graft that's pre-cut for the biologic tuboplasty. The next thing we do is we're going to get our graft and convert it into our anchors. We'll grab the repair in the round together, and now we'll shuttle our repair stitch through our graft. There we are. And then now we will convert it through the anchor after the shuttle. Now we'll proceed to the anterior aspect of the graft and we'll do the same thing. We'll grab our round and repair, and then we'll pass our repair stitch through the graft with our previously passed links. And then we convert the repair stitch through the anchor. And there we have it. So now we have our repair stitches nicely placed. So we have some gentle tension on our lateral sutures. So now we're ready to pass our graph through the passport with a little lateral tension as we said. And immediately we're just going to kind of ratchet this in with back and forth, back and forth ratcheting that in. And sometimes we'll just squeeze this into the cannula a little bit, help it along as that's flowing in nicely through the cannula. And again keeping our gentle lateral tension as we're going through. And there's our graft. All right. Pretty good there. So at this point in time do you cut these repair sutures or do you leave them? Chris I'd actually like to keep those in because I want to be able to retension this after we do our lateral fixation. So we'll take our posterior anchor. We'll bring our lateral stitch outside. And you can see that the graph is going to lay down nicely. It's basically going to lay down right there. So we have our self punching swivel lock in place laterally with our suture. And we're going to find our spot to place our graph. Laterally we'll cut our remaining sutures here. And then we'll switch over to the anterior aspect. Here's the lateral view of our completed procedure and why I like to do the cable reconstruction with the bilateral tuboplasty is because I want to preserve as much as possible the kinematics of the rotator cuff with the cable reconstruction, and get the benefits of the pain relief of the biologic tuboplasty.

Posterosuperior Rotator Cuff Tears: Rotator Cable Reconstruction With Biologic Tuberoplasty

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