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NanoNeedle™ Scope 2.0
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Pitcher's Recovery

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.

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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.

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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.

Tips for Efficiency in Shoulder Arthroplasty Surgery

OrthoPedia: Tips for Efficiency in Shoulder Arthroplasty Surgery

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

Distal Biceps Tendon Repair Using the TensionTight™ Button

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

Distal Biceps Tendon Repair Using the TensionTight™ Button

J. Lee Pace, MD (Plano, TX), demonstrates a technique for medial patellofemoral ligament (MPFL) reconstruction using onlay patellar fixation with Hybrid Knee FiberTak® anchors and femoral fixation with the FiberTag® TightRope® II PF implant.

Patellar Onlay Technique With Suspensory Femoral Fixation for MPFL Reconstruction

Hello, my name is Lee pace from Plano, Texas. I am an orthopedic surgeon with a specialty in sports medicine and knee surgery, and I'm here today to show the new Mpfl reconstruction technique using a patellar inlay technique as well as a new mpfl fiber tag tightrope for femoral fixation. So we have a graft here on this disposable graft prep and sizing table. And this is really nice when you're using autograft tissue because you can use this as we're going to show here to scrape muscle off just like this. This stuff just comes right off. Just like that. You can see you can really very easily get all that muscle off of a tendon when you're doing your mpfl reconstruction. So here we have a prepared gracilis graft for an mpfl reconstruction. We want to make sure that this portion of the graft is going to fit through a six millimeter femoral tunnel. So we're going to size that right now. So we're just going to bring this through here and pull this up. And there you can see that that fits very easily through that. We can probably pull that all the way through just like that. So we have a good graft size here. And then another thing to highlight on this graft prep table is at any point during graft prep, if you if you need to or want to, you can actually use these cleats to be able to hold the graft steady and add some tension. So I can just wrap this around here just like this. And now this one side of the graft is is going to be held stationary just like that. And then also if I want to I can also do the same thing on the other side as there's cleats on both sides of this graph prep table. So we've done a standard medial two incision approach for an mpfl reconstruction. Here is our femoral incision right here. That's typically going to be made under fluoroscopic control. Here is our patellar incision. And you can see we've got the medial aspect of the patella exposed. There's a medial patella. There's the joint right there. You can see I've marked out our anchor placement. This is about midway on the patella. And this is about 25% down from the superior pole. So we're going to place an anchor here and here. And then we're going to do an on lay technique to secure the graft between these two anchors. So here is the knee fiber tack ratcheting guide that we're going to use to drill our patellar sockets as well as place our anchors. So you can see this has a ratcheting mechanism with a release mechanism right there. And it's got a spike on one side. And that is meant to anchor in to one side. You can do this percutaneously and just kind of stab through the skin. Or if you would like to, you can also get an idea of where you want to put it. And you can make a small stab incision like this. So usually you want to start and get the lateral side in first. So I'm going to get this down. I can feel very firmly that I am on the lateral aspect of the patella. And then this just simply ratchets down. And I'm going to put this right over my purple mark. So I've got the ratcheting fiber tack guide in place. You can see that it's secured against the lateral patella and the medial patella. So I can kind of move the patella back and forth like this. This is very secure. This will allow very reproducible socket drilling as well as anchor placement. This is just going to bottom out. And then this fiber tack has a blunt inserter to allow for easier insertion on the mobile patella. Take this off. Move this. And then the anchor is in. And now I'm going to set it. So I'm going to pull. And you can see that that is very firmly in place. That is not coming out. Okay. So then I can place the second one. So I'm going to just kind of put it over the spot where I want to put the second anchor. I'll take a second. I'll make sure that that gets right down on the patella. That's very firmly on the patella right there on the lateral patella. We're going to come in here and we're going to just retract that up just a little bit. So I can see where that second mark is. And that looks good right there. Ratchet that down again. You can see very firm control of the patella right there 2.8mm hard bone drill. Bottom it out. And then look at that. Look at how much that actually inserts just with hand pressure. Finish it off with the mallet. And now we'll set this anchor. And again that is firm in there that is not pulling out. Okay. We're going to drill and prepare the femoral tunnel next. This is the Radiolucent Fluoroscopic guide for Shuttles Point which you can use at this point with lateral fluoroscopy. We've already determined where we want our femoral socket to be. So we're going to then take our Beath pin our spade tip Beath pin. And we're going to drill this across the femur. That's just going to poke out the skin of the lateral thigh. So now we can take our low profile six millimeter reamer. And we'll take that over the Beath pin. And you can honestly just take this to the next cortex and don't violate that. But that way you've got all the room you need in case your graft is a little long. And then from there we can switch this out to a fiber snare. And then we can just luggage tag this for later. Okay. Now we're going to fix our allograft on the patella. We've made a mark here at the midway of the graft like so. The first thing we're going to do is we're going to shuttle it through these two loops. Okay. And then we can just start tensioning this down. And we just take it each one at a time. And we're just going to make sure that as we get close that we keep that midpoint in between these two loops. And as we bring it down, you can see we've got our purple midway point basically perfectly between those two. And so we can just continue to cinch that down and cinch that down like that. And so we've got very good fixation now of that gracilis graft right on our medial patella. And you can see I can pull very firmly on that. And those anchors are not coming out. We've got very good onlay fixation of that graft on the patella. Now the next step, we're going to take a little measurement of how much gracilis graft we still have. You see if I can drag it down here that it is definitely going to be long enough. The question is, is it too long? The answer is probably not, because we have such a long femoral socket. But if we want to take an extra measure of precaution, we can measure how much length we have here. And you can see that we've got almost 9cm or 90mm of length. And we know that the mpfl is roughly about, on average, 65mm long. So if we want to, we could actually shorten this graph down. Maybe a centimeter, centimeter and a half. And we know that we're still going to get probably, you know, 15, 10 to 15mm of graft inside the femoral socket. So once we've kind of made that determination, if we do want to shorten it or if we're happy with what we've got, we can then remove our graph prep sutures and we can apply our fiber tag tightrope. So next we are going to fix this new mpfl fiber tag tightrope to the free ends of this gracilis graft. Okay, so the thing to point out is that this fiber tag is slightly smaller than what you would use for an ACL. So this is designed specifically for an mpfl reconstruction. And so what we do is we take this off of this backer card just like this. This will unroll. And this comes off. And now we've got this. And this is going to be very similar to an ACL reconstruction. So I'll take the tenaculum clamp next. And so this works just like it would for an ACL is we're going to take keep this little slot on top right there. Keep that little slot on top. This is going to feed into that. So we have the fiber tag now snared through the superior jaw of the tenaculum. And then once we have that then we can get the graft and we can pinch it all down together just like that. Okay. And then from there, it's just a basic suturing exercise. And now once we've got this, take the tenaculum clamp off, and then we can just simply just remove this just like that. And now we have our loop and we have our pull stitch, and we have our tightening sutures right here you can see that this loop is a little short. So we are going to lengthen it to make sure we have enough to get across the distal femur. So that should be we just even this out a little bit. That should be enough to to get us across the distal femur. The last thing to point out is that this is like the original tightrope, in that the tensioning sutures are actually going to be back here, and we're going to tension through the medial side. It's not going to be like an HT tightrope where we're tensioning on the lateral side. Now as we get ready to pass we can go ahead and we can cut these sutures right here. Now we're going to dissect out the plane between layers two and three, so that we can pass the graft from the patellar side down to the femoral side and then shuttle it into the femoral tunnel. So just dissect down like this. And I often will just get my my finger in here and just make sure that I can feel my scissors. I also want to make sure I do not cut my suture and I am. So now we're going to take a snare, bring that up, and then we're going to take all of our suture. Fold it over. Pull it down just like that. Okay. And now what we're going to do is we're going to take our blue sutures only. To pass the graft into the femoral tunnel. Okay. And now we can pull that through. Let me take this. And I'm just going to hold a little bit of back tension here. Okay. Go ahead and pull the button through. And you can do this with fluoroscopy in a live situation to make sure your button flips properly. But it feels like we just got the button through. So I'm going to just kind of pull back. And again we can usually check this with fluoroscopy, but it feels like the button is flipped because I am pulling back on the graft and I'm not getting anything to come back on me. Now we are just going to tighten the adjustable loop of our tightrope. So I like to have an assistant hold this. And we'll just shuttle this down until we're close. And I'll usually stop there. And then we'll bring it up through the under the patellar side of things. And this is my check rein to make sure that I don't over tension it. So I've got the knee flexed roughly 4550 degrees. That way, the patella is solidly engaged in the central to distal trochlea. So I know it's exactly where I want it to be. And now this is going to prevent me from over tensioning the tightrope. So if we look you can watch the graft tension over the clamp. Just like that. And once you feel like you've got some resistance there. Again, this prevents this allows you that one quadrant of translation. Once you've got a little bit of residual slack, you can then take it out. And then you can check your translation. So you can see here that I've got still about a quadrant of lateral patellar translation. So that's going to be pretty perfect. That's exactly what we want. So this is our way with this clamp to minimize the chance of over tensioning. It makes the tightrope technique very reliable. Now, typically what I would do at this point is I would take the knee through a range of motion, and I would confirm that there was no increased tension on the graft in deep knee flexion. And if that is confirmed, we can then proceed with cutting these sutures. We can remove the blue pull stitch. And now we can use these sutures to close our retinaculum. This is a 1.3mm suture tape. And as you can see this is all one long suture with a needle on either end. So we can come through the retinaculum here. So you can see the final retinacular closure here is complete. We've got good knots placed here and that is completely closed down.

Patellar Onlay Technique With Suspensory Femoral Fixation for MPFL Reconstruction

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

DualCompression Hindfoot Fusion Nail Demonstration

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

DualCompression Hindfoot Fusion Nail Demonstration

The consolidated trays for the Univers Revers™ total shoulder system are designed to provide a cost-saving solution that preserves patient-specific optimization and enhanced operative workflow.

Univers Revers™ Total Shoulder System: Maintaining Global Patient Parameters With Fewer Trays

Speaker  Shoulder arthroplasty is evolving and so are we at Arthrex. We're giving surgeons a streamlined path to surgical excellence. Fewer trays with the same versatility you've come to expect. All to help you treat your patients better. The result? A dramatic reduction in O.R. waste and significant cost savings without compromising implant modularity or patient optimization. Our new consolidated system lets you perform a standard reverse case with just two trays and an augmented glenoid with only three trays, saving you space and streamlining your workflow, all while continuing to use the implants you're familiar with. Backed by over a decade of clinical data. Fewer trays. Same implant options. More efficiency.

Univers Revers™ Total Shoulder System: Maintaining Global Patient Parameters With Fewer Trays

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

Peter C. Yeh, MD (Stoneham, MA), shares a surgical pearl for using a weighted clamp to optimize graft passage during all-inside ACL reconstruction.

SpeedPearl: All-Inside ACL Reconstruction Using a Weighted Clamp

All-inside ACL reconstructions require a level of precision and preparation, as proper graft and suture management are keys to ensuring a smooth case. Here's a simple but very effective way to pass the graft into the femoral socket. Rather than having an assistant's hand pulling on the tibial shuttle loops, I use two clamps to weigh down the tibial shuttle loop suture that comes out of the Am portal and tibial incision, taking advantage of gravity to tension it down and out of the way. The heavier the clamps, the better. This allows for ease of graft passage, but more importantly also frees up an assistant's hand to do something else to further the case. One clamps both sides of the tibial shuttle, stitch both the Am portal side as well as the tibial incision side. For extra weight, I put an additional clamp on just the suture loop coming into the Am portal to make it even heavier. This allows tension on the suture and allows for the passage of the graft without worry that the tibial shuttle sutures will get pulled in.

SpeedPearl: All-Inside ACL Reconstruction Using a Weighted Clamp

At the Hand and Wrist Fellowship Forum, Damon C. Adamany, MD (Phoenix, AZ), leads a case-based panel discussion with Michael Garcia, MD (Tampa, FL), Walter McClelland, MD (Atlanta, GA), Mollie Manley, MD (Akron, OH), and Steven J. Lee, MD (New York, NY), focused on complex distal humerus fractures and appropriate fixation strategies.

What's NewAUG 15

OrthoPedia: Current Concepts in ACL Repair

What’s New This Week and Prior

AUG 14

Supine Suspended Elbow Positioning With the ElbowLOC® Arm Positioner

AUG 13

Technique Overview: Syndesmosis TightRope® PRO Implant System

AUG 12

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

AUG 11

Successful Setup and Use of the Arthrex Hip Distraction System

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Medical Education

Corporate

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Patient

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What's NewAUG 15

OrthoPedia: Current Concepts in ACL Repair

What’s New This Week and Prior

AUG 14

Supine Suspended Elbow Positioning With the ElbowLOC® Arm Positioner

AUG 13

Technique Overview: Syndesmosis TightRope® PRO Implant System

AUG 12

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

AUG 11

Successful Setup and Use of the Arthrex Hip Distraction System

NanoNeedle™ Scope 2.0 Gains National Spotlight Through

Star MLB Pitcher's Recovery

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Corporate

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