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NanoNeedle™ Scope 2.0
Gains National Spotlight Through

Star MLB
Pitcher's Recovery

Patrick J. Denard, MD (Medford, OR), describes a surgical pearl to maneuver and open the CuffMend™ graft spreader in a tight subacromial space to position the ArthroFlex® human dermal allograft.
ArthroFlex® is a registered trademark of LifeNet Health.

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video

SpeedPearl: Opening the CuffMend™ Graft Spreader in a Tight Space

Sometimes you can encounter a tight space when doing a koufman augmentation. So one tip I like to do is start by having your wrist turned away from you. And then as you insert the lateral cannula, you want to pronate toward you as you open the graph spreader. That will really allow the graph spreader to lay right over the top of the rotator cuff.

SpeedPearl: Opening the CuffMend™ Graft Spreader in a Tight Space

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

Endoscopic Approach to Lateral Recess Decompression

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

Endoscopic Approach to Lateral Recess Decompression

John Munz, MD (Houston, TX), describes how he uses BoneSync™ bone void fillers in his trauma practice and presents a case using BoneSync cement during a proximal tibial fracture repair.

BoneSync™ Bone Void Fillers for Proximal Tibia Fracture Management

Speaker  Hello, I'm Doctor John Munns from Houston, Texas. I practice at UT Health Houston. And today I want to discuss Arthrex bone sink for the management of Metaphyseal voids. Bone sink is a cement product that's easy to use. It's fast remodeling, suitable drillable and moldable, and comes in a self-contained delivery syringe. This is also available in putties and strips and provides an osteoconductive material. This is particularly helpful in the management of metaphyseal voids in articular fractures. Applications in my practice include tibial plateau fractures, tibial pilon fractures, and calcaneus fractures. I want to present a case today. This is a 60 year old female ground level fall. You can see from the X-rays this lateral split depressed tibial plateau with a significant articular depression going through the axial, coronal and sagittal images really highlights the amount of metaphyseal crush and the void you're going to have after providing reduction of that articular surface. This is something you have to plan for. You have to backfill that void. And we have a lot of options. We have allograft and we have cement type products during the surgical reconstruction, using a universal distractor to visualize that joint. You can provide reduction with either Tamps or Osteotomes. Once you have that articular reduction, provisional Kirschner wire fixation, but you can see the large void left behind. You have to address this, and Bone sink is an excellent product for this. Here the application of the bone sink in the metaphyseal void plate fixation, really securing the condylar width, the alignment stability, and the articular reduction. But one must also stress the need for any residual soft tissue injury and then address those accordingly. Final images here just showing the AP lateral of an anatomical joint reconstruction, and then that metaphyseal void that's been filled. In conclusion, bone sink cement is an excellent option to address metaphyseal voids after articular reconstruction and can help you treat your patients better.

BoneSync™ Bone Void Fillers for Proximal Tibia Fracture Management

Stephanie Pearce, MD (Jacksonville, FL), demonstrates an osteochondral allograft transplantation using the 20 mm precut OATS® kit.

Osteochondral Lesion Treatment With the 20 mm Precut OATS® Kit

Speaker  Hi I'm Doctor Stephanie Pierce from Jacksonville, Florida. Today we're going to be working on a 20 millimeter osteochondral allograft transplantation with the Arthrex 20 millimeter Osseo pre-cut kit. This is a convenient option for this size of an osteochondral lesion. In the kit is the dual tamp dilator. This tool is very intriguing. It has the dilator and measuring guide directly on one end. You can see these measurements here allow for easy identification of the depth of the lesion to match your graft. Additionally, there is a guide pin cannulated slot, so this will slide over the guide pin in the center of the lesion to allow for consistent and reliable entry in a seamless fashion into the lesion itself. The Tamp on the other end allows for easy entrance of the OCA graft into the lesion to allow for smooth tamping and flush fit at the completion of the case. So this is the graft delivery tube. This allows for arthroscopic insertion and completion of the OCA allograft, and you can see the dual Tam dilator easily fits into the tube to allow for ease of dilation during the procedure, as well as ease of graft, delivery and graft entrance. So as you can see, we've started our approach. We have a midline incision with a medial parapatellar approach. Here you can see I have marked the superior medial corner of the patella in order to allow for appropriate tensioning of the joint capsule. Speaker  At the completion of our case, after the graft is in to allow for appropriate biomechanics of the knee joint at the end of the Osseo grafting. And here in the center of our medial femoral condyle, we see our lesion. Now this lesion measures approximately 17mm by 19mm. So it's quite large really giving a great option for this 20 millimeter pre-cut OCA graft kit. First I like to take the dual Tam dilator. And we can use this as a measuring guide. It has these beautiful measurements here. And you can see it runs really nicely on the cartilage. So you can find the best position to get the best read. Right now, we can see that the 20 millimeter guide will cover the entirety of our lesion, but is not too large for how large our lesion is. So this is a great fit. Finding the center of this lesion is important. That's where our 2.4mm guide pin is going to come in. And this dual tamp dilator allows us to get right in the center of our lesion and come in directly in the center with our guide pin. You need to enter just enough to get a good hold. And you can see that guide pin is going to be aligning nicely for our reamer. As we're getting ready to ream, we want to ensure to be using fluid to minimize the bone death. And heat damage to the recipient site. Speaker  The nice thing about this reamer is that it has measurements on the reamer itself. So you can see we're coming about to a depth of eight 8 to 10mm, which is ideal. So we'll stop here. Now the reaming is done. We'll clear the debris out of the site here. So after cleaning all of the reaming you can see we've marked the 12:00 position, which is really important for orientation. And in comes the Cannulated dual end tamp also working as our measuring device. So we can see right now it is at ten millimeters at the 12:00 position. And we can get all of our measurements around at each of the 3:00, 6:00 and 9:00 positions. This is one of the strongest pearls that I can recommend, is making sure that we have those precise measurements at each of those corners. That allows for smooth contouring to recreate the articular surface at the contoured shape of the patient's host recipient site. That's going to allow the best match for the Osteochondral allograft to help minimize wear deterioration and improve incorporation and integration of your OCA. So now we've taken the guide pin out and we're going to leave the dilator in place. This will help protect the recipient site, but it will also help create an easier passage of the OCA into the recipient site at the conclusion of the graft preparation. All right. Speaker  So now we're on our back table and we're working with the graft itself. So this is a really nice option because this comes pre-cut and delivered from the package exactly like this. Other than the fact that I marked our 12:00 position. So this is how it is out of the package ready for ease and use. The first thing we want to do is measure the depths. So these need to match. So I like to use a clock face to do this. Some prefer a compass rose, but for me, measuring the 12:00, the 3:00, the 6:00 and the 9:00 are crucial to allow for appropriate contouring to match the host site. That way, there's the least amount of degeneration of the osteochondral allograft. So as we're doing our hour measurements, I like to make sure I have two hands to guide our depth to be as accurate as possible. So the 12:00 is at ten millimeters. We'll rotate to the 3:00 position and that's going to be at nine. Our 6:00 is at 11 and then our 9:00 is also 11. Beautiful. And then I like to connect these. This helps guide my saw blade to ensure an appropriate contour which increases the graph matching reliability. Very rarely do these come exactly equal all the way across. So having this reliable method to create a perfectly matching graph to the host makes this a much more streamlined procedure. So now you can see we have measured the depths of the graft along the various clock face measurements. Speaker  And this allows for an appropriate matching for the contour with the depth of the lesion that has been taken. So I like to use stable towel clamps to hold our graft. So now that the graft is held securely with the towel clamps, it's available to allow for sawing to taper this to the exact size and depth that's needed. Once again, very important to ensure fluid is running during the sawing so we can minimize cell cell death and encourage bone to bone healing and integration. As I'm positioning the graft, I like to have the largest area that needs to be removed closest to me. This allows for the least amount of sore passes in order to have a more efficient cutting method. The graph is toggling, so I readjusted the clamp so that it will have the least amount of movement as the sore is coming across. You can see it's much more stable. Another tip is you can take either the edge of the saw or the rongeur to bevel the edges. That will allow for easier entrance into the dilated recipient site. Now our graft is ready to be soaked with ACP or autologous fluid of your choice. All right, so now we're back to our recipient site. We're going to remove the dilator and this is a key Pearl is to. Speaker  Now lay down a suture tape. The suture tape gives much more control of the graft during insertion to allow for any readjustments or. If you don't like the position of the graft or the depth of the graph, you can take the graph completely out without causing any damage to the cartilage. And now we will insert the graft matching the 12:00 positions. And we'll have our Tamp ready. This is going to be a good tight fit. It's going in really nicely. So a couple of light taps as you're moving around. Always dispersing the forces is really important. Remember remember the chondrocytes are are alive. So you want to have the least amount of traumatic damage to them as possible. And then once it's seated, which is when seating really nicely, I like to take a 15 blade, and this helps to get the fine tuning for the final position to really maximize the cartilage matching for the contour. These are very small slivers, if you will, especially since there's no matching with these pre-cuts. Sometimes you need just a little bit of fine tuning to make it perfect, but it still is a wonderful option. At a faster rate to be able to create a beautiful matching graph with a gorgeous contour matching the patient. And there you have it, a 20 millimeter osteochondral allograft from a pre-cut plug using the Arthrex 20 millimeter pre-cut OCA kit.

Osteochondral Lesion Treatment With the 20 mm Precut OATS® Kit

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

Raymond J. Gardocki, MD (Nashville, TN), reviews thoracolumbar interfascial plane (TLIP) blocks and how they can improve analgesia and enable minimally invasive and endoscopic spine surgery in the outpatient setting.

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Interfascial Plane Blocks

OrthoPedia: Interfascial Plane Blocks

Marc W. Gerdisch, MD (Indianapolis, IN), demonstrates a technique for reinforcing and closing a partial sternotomy using a combination of FiberTape® sternal closure and DynaNite® CT nitinol staples. After evaluating sternal depth to determine the appropriate staple sizing, the sternum is approximated with FiberTape sternal closure sutures before drilling and deploying the DynaNite CT staples to provide targeted compression across areas such as the J-incision and the manubrium, helping address residual gapping or motion that may remain after approximation.

Partial Sternotomy Stabilization Using FiberTape® Sternal Closure and DynaNite™ CT Nitinol Staples

Speaker  To restabilize the bone. We're going to use fiber tape, sternal closure with dynamite CT nitinol staples. And in order to use the dynamite staples, we need to know the depth of the bone. They come in two depths, ten millimetres and 12mm. And then we want a cushion of two millimetres. So if we use a ten millimeter, we have have to have a 12 millimeter sternum. So looking down here at this thinner part of the bone, we've got 12mm. And up here, if we happen to go later to the thicker part of the bone, we've got roughly 15 or 16mm. So we would use the ten here and the 12 up here. Before we deploy those staples though, we can actually get the bone set up stabilized approximated using the fiber tape. So we'll do that. Now the dynamite staples, we can use them in a couple of different positions here. One is going to be down here where we created our J, which is actually incredibly well approximated already. So because there could be some instability, we're going to put our dynamite nitinol staple there. And we decided here that we're going to use, as we mentioned earlier, the ten millimeter version for which we need 12mm of bone. So this is the drill guide, which lets us drill to a precise depth to accept the nitinol staple. Speaker  And we want the tips of the nitinol staple. Then to line up with those holes that we're going to create. So we can see that width there. So I can actually widen this. I'll spread the nitinol staple. And as you all know, these are incredibly elastic. So it will go back to its original position creating tension once it's inside the bone. So I still have a little more to go. So I've spread it now to fit those holes. And after we have the drill holes, we'll be able to pop it right in there. So we'll apply the guide across the the piece of bone that we're bridging and then create our guide holes. Then the staple will slide into those guide slots and down. If you feel like it's not going all the way down, you can tap this a little bit, but usually you don't need to. And then you just loosen this now and that will free the carrier from the staple. And now the staple is down in the bone. And we have this little tamper. And that allows us to set it into the bone completely. So now that it's in the tips are doing this automatically, right? Because they're nice and all and it's flush to the bone. There's the staple right there and it's perfectly flat now. Speaker  And it's creating tension this way. And that will stabilize the bone there. And I cannot move it. So it's working quite well there. So if we wanted to really optimize stability here, I would look for those places where it's got a little bit of movement. And then again, this will be the larger staple now. And now earlier I could really see this kind of bouncing apart. Now, with that same force, I can't really get anything. So I know that Diane and I staple doing what it's supposed to. It always surprises me when I see these go in and just how transformative it is with respect to the rigidity of the closure, because we don't have any gap there anymore. In summary, then we use three fiber tapes here, which gave us superb approximation, some strength from the back with the XS on the back there overlapping in the intercostal spaces. And then where we saw this bone had areas of what we felt were instability and lack of rigidity. We added dynamite staples here as well. And if you were paying attention earlier, when I did this on the manubrium, I had a little gap that I was creating. The gap cannot be created any longer. So we've got a really nice closure.

Partial Sternotomy Stabilization Using FiberTape® Sternal Closure and DynaNite™ CT Nitinol Staples

Aaron J. Krych, MD (Rochester, MN), demonstrates meniscal root repair using the SutureLoc™ implant and a FiberStitch™ 1.5 implant to augment the repair.&nbsp;

Meniscal Root Repair Using SutureLoc™ and FiberStitch™ 1.5 Implants

Speaker  This is Aaron Critch from Rochester, Minnesota. And I want to show you how we performed this root repair with our suture lock and 1.5 fiber stitch configuration. Today we have a left knee. And here you can see we're looking in the medial compartment. And this is a typical root tear or radial tear near the root. And today we want to show our suture lock root repair with fiber stitch augmentation for this very common case. So in this in this case you can really appreciate the root footprint anatomy. So the first thing we want to make sure is that we can see well. So we've already taken a little bit of the PCL synovium. We've lengthened the MCL a little bit. And here we're in good shape to work. So the first thing is to make sure that we have good mobility. And you can see this is one that really doesn't have much extrusion. So we're in good shape. Now we're going to think about the biologic Preparation. So it's very important that we prepare this as bleeding bone so that we get our onlay fixation. Different ways to prepare the bone here. I'm just using a simple curette, but we can use the power rasp, other types of rasps to help. But it's very important step that we make sure we're getting to bleeding bone because we want our meniscus to heal to that construct. We don't need a socket anymore. We can get all onlay fixation and healing. Speaker  But again, it's very important to prepare this to bleeding bone. So here we've got a nice curetted base. Now we want to remove any soft tissue. This is the SE 50 reaches back here into the footprint. Very well. We just don't want anything to hold up our suture lock passage. So I'll just make sure to take that out. But it's a very good anatomic landmark of where we want our two four pin to come out. So the first step is to place our augmentation suture. And we're going to do that with the one five fiber stitch. So we're going to place our portal skid. And then we'll take our fiber stitch and bring this in. Now the fiber stitch will serve dual purposes here. So one is to augment this meniscus to the posterior capsule. The second is this will provide our rip stop sutures for our suture lock root repair construct. So I don't want these sutures right on the edge. I actually want to start them here because we need to bring that meniscus over to the footprint a little bit. We want to make sure we're thinking about centralization and extrusion through our anatomy. So we'll place the first fiber stitch through the capsule. And then here we really want a nice broad footprint of the fiber stitch. So I'll try to get as close to the edge as I can. And that will provide a little bit larger backstop for our rip stop construct. Speaker  So here we'll place our our second throw. There are other ways to perform rip stop sutures. You can tie a freo a free two suture using the knee scorpion. You can also use somewhat of a Mason Allen construct on the suture lock itself. But here we're just going to tension to the capsule. Here I want to make sure I don't over tension the construct. We want to keep the mobility of that meniscus. We can get it back to its root footprint. But this does a nice job because we get a double suture construct for our rip stop. So what's nice about using the fiber stitch is it's relatively quick and we don't have to think about any suture management. We can just get this out of our way. For the remainder of the case. So now we've got our passport cannula in our medial portal. So we'll just take a look at our fiber stitch here a little bit more closely. So we actually have a nice circumferential rip stop suture configuration. And now we'll move on to the rest of the route repair. So we'll take our point to point guide next. We have this set at 70 degrees. We like this point to point guide because it does a very nice job of recreating the anatomy. It's very important to be precise. We know that if even if we're off five millimeters with our root origin, we won't recreate the biomechanics of the meniscus. Speaker  So another feature of this guide is that it can swivel. So in this case we're going to drill from the medial portal to the anteromedial tibia. So some swivel there helps significantly. And then once this is set, then we can make our small skin incision. So we've got a great view here with our panel scope. We can really see the recreation of the anatomy. You can see where we decorticated to what would be bleeding bone in our knee. And we're going to drill now our 2.4mm cannulated drill pin. So we'll watch this drill pin come up. And this is great at this point to point guide really has a lot of accuracy, really helps us get into the right location. So at this point we'll uncouple and uncheck our 2.4mm Cannulated pin. So here we're going to pass our nitinol wire loop. Through our 2.4mm Cannulated drill pin. What's nice here is this is all one step. We don't have to exchange a pin. Makes it very efficient and streamlined. So we're going to take a Grasper. We'll go through our previous cannula and go ahead and grab that. And then we'll get the cannulated pin out. So now one tip is that we like to exchange this wire for a fiber link. This fiber link suture shuttle tends to be a very smooth way to shuttle our suture lock through our tibia. Speaker  Sometimes the wire can cause a little bit of friction and get hung up. So just to ensure that doesn't happen, we'll use our fiber link. So we have our suture lock implant ready to shuttle. So you can see on one side our repair and conversion sutures and on the other side are tensioning suture. So when we shuttle this, we want to make sure that we have enough of the sheath to shuttle, but not too much. So we want this folded over just beyond where our sutures come out. And then we're going to convert this through our tibia. Once we have all those sutures out, one little trick is we can take a little hemostat or mosquito just to prevent these sutures from converting. So one of the important steps is to deploy our implant right underneath the subchondral bone. So here we're going to deliver it right through our 2.4mm drill hole. And I can really feel that pop. And then I want to make sure that this implant and anchor are right underneath the subchondral bone. So we can see there's a tensioning loop, and then our two converting sutures come out the tibial part of the implant. So we're going to take our tensioning loop right now. And we're actually going to deploy the anchor. So right now that anchor is balling up. And then we want to make sure it's right under subchondral bone. So I'll actually do a little bit of back and forth where I'm pulling the anchor against Subchondral bone. Speaker  I'll bunch it up a little bit more. I'll pull it against the subchondral bone. So that way we ensure that it's right up where we need it to have our fixation. So at this point, I'm going to clamp our suture sheath just to make sure we don't accidentally convert or run one of those sutures. And then for suture management we'll take a suture grasper. And I actually like to park everything out the lateral portal because that just helps maintain everything, avoiding any suture entanglements or potential issues. So we'll make sure we've got our two blues, our two whites in the conversion. We'll pull everything out Our lateral portal. So now we have all of our sutures. Doctor. Lateral portal. So now it's dealer's choice. If you want to do the white repair suture the blue repair suture first. I tend to have consistency with my team. So I'll always do the white in the back and the blue in the front. So now we'll take our knee scorpion and we'll pass our sutures. So we'll just load the end of the suture in the knee scorpion. And what's nice about using our one five fiber stitch as our rip stop construct is now we can place two simple sutures. So this first one we want way in the back. And I use the edge of the knee scorpion as our guide in terms of medial to lateral. Speaker  How much meniscus that we want loaded in the construct. So now we'll grab our white and black converting suture that's parked in our lateral portal. And again, just keeping everything kind of tidy with our suture management. So there's a nice loop and there's a colored dot here. So we know exactly how much suture to fold over and convert through our tibia. And then while that's being loaded we can find our working end of the suture down here on the tibia. So here you just want to make sure we separate our two converting sutures. So I'm going to pull the white and black. And that easily converts through the tibia. Now we'll tension this suture just a little bit just till we get the slack out so that we have room with our next suture. We want to tension just a little bit more. And we really want the suture to come off the sides. I'm having my assistant pull a little bit of slack out of that repair. And I want this to come on the side of the meniscus. And once you see it sitting in back, that's a perfect amount. So once we have that provisionally tensioned, then we're just going to replace our clamp here just for safety. So we don't run the sutures. Then we're going to take our grasper and grab our second repair suture. This is our blue one here. So we'll pull that out our passport and we'll get that loaded in our knee scorpion. Speaker  So we're ready for our second suture pass. So we're going to come in place our second simple suture. And here we want a nice spread. So you can see where our first one is. We want a good bite of tissue. But we want a nice suture bridge between the two. So now we're going to pull this out our portal. And we have a small girth hitch which is very easy to deal with. We just clear the loop. And then we'll grab our conversion suture. So we have both those outer passport cannula. And again we're lining up that black mark on the suture. While we're doing that we're finding our second conversion suture in the sheath. So our blue and white is here. So we're going to convert our second repair stitch. And now we have our suture construct set. So I'm going to have my assistant grab one blue and one white. And we're going to take the slack out of our blue repair suture first. And we're going to get this lined up. So sometimes what I'll do is I'll grab the meniscus. This is a nice pearl because I really want these rip stop sutures to work. So now we're adding some provisional tension. We'll add more in the blue. And you can see that blue is kind of sitting in the back. So we're just going to grab it here. Speaker  We'll keep pulling on the blue. So now you can really see our our ripstop configurations. At this point I'm going to move to a probe. And again we really you can see how this meniscus is detention right now. We need to get back to our root origin. So at this point we're going to sequentially tension. And that's one of the great advantages of this implant as we can tension and retention. So we're going to go ahead and continue to tension this down. And you can see how important that ripstop fiber stitch is. So that keeps our sutures from coming through degenerative meniscus tissue. This does a nice job. Remember we decorticated all of this cartilage. So this is compressed against bleeding bone. And you can see this does a nice job of bringing the meniscus back in. So we don't have extrusion issues. And again you can really see that ripstop configuration. One of the advantages. If we had more surgery to do at this point, we could retention when we're done. So for example, if we had an ACL, we could come back and retention. If we're all done at this point, we can also trim the sutures. But the fixation is right here at the subchondral bone. We don't have fixation lower on the tibia. So again any combined surgery with ACL with PCL we don't have to worry because we have direct suture lock anchor fixation. So really we have a nice ability to tension retention. Speaker  You can really see how our rip stop here is critical. And that does a great job. We're just going to check that out with our probe. Look at how that suture lock just locked. This whole meniscus root right into place. Really gives us a lot of confidence for healing, for rehabilitation. But really it gives us a nice wide footprint of compression. So you can see we've got the suture in the back. We've got the suture in the front. So this entire area of meniscus is being compressed to bone. So really overall a huge advantage over our previous transtibial pull through. But really, really a great construct with our one five fiber stitch and our suture lock. So we can see our construct. And what we're going to do is we're going to do our final tension. We're going to bring the knee now to about 80 or 90 degrees sometimes. You know, it'll be a little bit tighter at 30 and a little bit looser with that femoral rollback. So here we're going to do our final tension now at 80 or 90 degrees. And you can see how we have complete compression of our meniscus root repair. So once we have our final tension the construct now we can simply trim all the sutures from the sheath. Again. Remember our fixation is in the joint at the subchondral bone. And now all of this tibial real estate is available for other procedures.

Meniscal Root Repair Using SutureLoc™ and FiberStitch™ 1.5 Implants

JumpStart® antimicrobial wound dressing with Advanced Microcurrent Technology is used for the management of surgical incision sites. Embedded in the dressing are microcell batteries made of silver and zinc, which generate an electrical current and kill a broad spectrum of harmful pathogens, including multidrug-resistant and biofilm-forming bacteria, to help reduce the risk of infection.1
Reference 
1. Kim H, Park S, Housler G, Marcel V, Cross S, Izadjoo M. An overview of the efficacy of a 
next generation electroceutical wound care device. Mil Med. 2016;181(5 Suppl):184-190. 
doi:10.7205/MILMED-D-15-00157

JumpStart® antimicrobial wound dressing with Advanced Microcurrent Technology is used for the management of surgical incision sites. Embedded in the dressing are microcell batteries made of silver and zinc, which generate an electrical current and kill a broad spectrum of harmful pathogens, including multidrug-resistant and biofilm-forming bacteria, to help reduce the risk of infection.1 

Reference 
1. Kim H, Park S, Housler G, Marcel V, Cross S, Izadjoo M. An overview of the efficacy of a 
next generation electroceutical wound care device. Mil Med. 2016;181(5 Suppl):184-190. 
doi:10.7205/MILMED-D-15-00157

JumpStart® Antimicrobial Wound Dressing

JumpStart® Antimicrobial Wound Dressing

Walter R. Lowe, MD (Houston, TX), demonstrates a BTB ACL reconstruction using the BTB TightRope® SB implant and the InternalBrace™ technique. The FiberSnare® guidewire is used to shuttle the FiberTape® suture through the cannulation of the FastThread™ screw to allow for independent fixation of the FiberTape suture.
 
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-tobone fixation.

BTB ACL Reconstruction Using the BTB TightRope® SB Implant and the InternalBrace™ Technique

What you see here is the equipment and graft needed to do a bptb ACL reconstruction with internal brace technique. And the fixation we're showing you is the bptb tightrope soft button for fixation on the femur. What you see on the left side of this is the bptb tightrope with soft button. What you see, the blue and white sutures are just like the old bptb tightrope for pulling the graft into the tunnel. You see the yellow soft button. Okay. And then off to the right side of the soft button, you'll see a tiger wire suture. That is really the only difference here from the old technique. And that tiger wire is what we're going to use to keep equal tension and keep this soft button elongated as it passes through the femoral tunnel. What you see below with the two drivers is the tap for the fast thread peek interference screw down below you see the interference screw with the fiber snare guidewire placed up through this screw, where we will use this to pull the internal brace down through the interference screw on the tibia for later fixation. This is the cadaveric specimen we're going to use to demonstrate the BTB soft button. I've taken the liberty of preparing this specimen so you can see femoral tunnel. I drilled this with with a flip cutter. You can drill it with your technique. As long as we know tunnel links to use a tightrope type fixation. Tibial tunnel was drilled with the flip cutter guide, but a full tunnel was drilled for this demonstration out the tunnel. So we'll start. And you can see we've already passed the wire to pull our graft into place. So we're ready to do that. So you see our suture. We're going to shuttle the implant in. And this is just like the old BTB for tightrope, where we're shuttling in the white and blue sutures to pull the graft into place. So now you'll see the tightrope soft button Slowly coming into place here, but said this part you can see looks just like we're using the old tightropes. So we've got the white sutures, we've got the blue sutures that are the guiding suture for the new. So on the tibial side, we're just holding on to the tiger suture. Everything else can just lay on the leg at this point in time. As we're getting ready to pull this in, you can see from our outside shot that the tightrope loop has been lengthened. So we want to set the soft button on the femur before we engage the tibial side of the graft and the tunnel. So I just flipped scope to the medial portal so we can see this better. And we're on the pano view. We're passing the graft with tension on both sides. So the same person right now should control both the femoral side and the tibial side. And you'll see this soft button the yellow coming into play. And now this tension is keeping on the tiger. Down below is keeping that button elongated as you see it. Go through to the lateral femoral cortex. So now to check the fixation. Just like old ways, I'm pulling on the internal brace. We're letting a little pressure off of the tiger. So that lets the soft button essentially ball up on the lateral femoral contact. So now that we've passed this we're just going to demonstrate, let's say something happened on the femoral side where the buttons outside the IT band. You got big dimpling or something. And you want to pull this button out. So what we're going to do is pull equal tension on the blue and white and on the tiger below. So that's going to elongate that button so we can pull it out. You see that. And now we can go through the same thing with equal tension. Will pull it back up. And then with tension on the femoral side, I will pull back on the internal brace. And that will set it up against the lateral femoral cortex again. So now we're ready to pass the graft using the tape grasper. Now I'm through my anteromedial portal and I am going to get the internal brace out of our way. So I'm viewing laterally now because the step I've done before, we start to engage the tightrope and pull our graft into place as I've moved the internal brace out through the intermediate portal. So with the internal brace out through the anteromedial portal, my assistant is just holding a little tension as we start to pass the graph, you can notice that I'm orienting the bone plug up into the tunnel, and we're slowly working it up, and you can see the bone plug coming into place. So now we have our graft oriented how we want it, and now I'm just checking the length of the graft on both sides. And it's in my thermal tunnel, which is good. Let's leave it there. And it's in my tibial tunnel. So that's sort of the picture I would like to see at this stage. And so now we're ready for tibial fixation. So at this step we're going to remove the tiger wire suture. And we're just going to keep gentle tension on the IB or internal brace right now as we pull this suture out. This is the fiber snare guidewire I've just put over the top of the tibial bone plug and the tibial tunnel. And so now since I have a passport here, I just need to retrieve the snare part. Out through the anteromedial portal, and we'll load our internal brace onto it later. Next we're just going to tap and the tap for the fast thread peak screw, and I'll take it all the way over the top of the bone plug. You can sort of feel when you come past it. So now I'm going to position the leg out, you know, close to full extension 1015 degrees. So now I'm, you know, got it. Tension distally and I'm putting the fast thread peak screw up. And so once we have the fixation on the tibial side then now using the fiber snare guide we're pulling the snare part of it down through the screw. You can see the tip of the interference screw right there. And now we're going to pull the internal brace through the screw. And it's very important that screw is you know the opening is tiny. So we make sure the internal brace we have the small ends of it as we pull it in. And so you can see it docked to it now. So we're going to finish the case by fixing the internal brace on the tibia in full extension with the swivel lock. So as we get ready for the fixation of the internal brace, it is really and critically important to move the knee into full extension. So now that we have graph fixed on both sides, internal brace fixed on the tibial side will cycle the knee a few times and then we'll retension out near full extension on the femoral side. You can see we got a little bit you know, and you can do this as many times as you want. So that's the final picture.

BTB ACL Reconstruction Using the BTB TightRope® SB Implant and the InternalBrace™ Technique

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

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

At the Sports Medicine Fellows Forum, Harris Slone, MD (Charleston, SC), reviews causes of ACL reconstruction failure and outlines a systematic, evidence-based approach to revision ACL surgery, emphasizing tunnel management, graft selection, and alignment and addressing concomitant pathology to optimize outcomes.

Approach to the Failed Anterior Cruciate Ligament (ACL) Reconstruction

OrthoPedia: Approach to the Failed Anterior Cruciate Ligament (ACL) Reconstruction

The PARS Achilles Midsubstance SpeedBridge™ implant system is a percutaneous, minimally invasive technique used to repair Achilles tendon ruptures. Using color-coded 1.3 mm SutureTape, the PARS system makes it easy to create a percutaneous locking stitch in the Achilles tendon, while staying inside the paratenon sheath.

Achilles Midsubstance SpeedBridge™ Surgical Technique

When using the parse jig for the Achilles mid substance SpeedBridge technique, a percutaneous incision is made in a transverse manner just proximal to the palpable rupture. Alternatively, a small longitudinal incision can be utilized. The tendon is grasped and the jig is inserted with the inner arms inside the peritoneum of the Achilles tendon. The first parse needle is placed in the number one hole in the jig to stabilize the construct, while passing the other needles and sutures in sequential order. Lastly, the white SutureTape is then passed through hole number one. The jig can then be removed, which pulls the sutures out of the incision. Separate out each of the five sutures, the white, blue, and black suture tapes, as well as the two green and white FiberLink sutures. Each suture should be tested by pulling light tension through ten cycles to confirm appropriate hold in the tissue. On both sides, past the blue SutureTape under and around both green and white. Fiberlink SutureTak twice and back through the loop, then advance each loop back through the tendon using the free end of the green and white FiberLink sutures. This creates the locking stitch. Two stab incisions are made one centimeter below the superior aspect of the posterior calcaneal tuberosity. Medial and lateral to the Achilles tendon. Within these two stab incisions, insert the guidewire utilizing the drill guide with the white centering sleeve at 45 degrees from the centerline of the Achilles in the coronal plane, and 45 degrees from posterior to anterior in the sagittal plane. Guidewire placement can be checked under fluoroscopy. These two holes are drilled with a 2.6mm drill and tapped for later SwiveLock insertion. A banana. Suturelasso is passed through the distal stump of the Achilles and out of the rupture site. The SutureTape from the proximal portion of the tendon are then passed through the distal stump and out of the stab incisions distally. The suture tapes are then loaded through the eyelet of the Rd 3.9 biocomposite SwiveLock anchors. The foot is plantar flexed 10 to 15 degrees to approximate the tendon ends. The SwiveLock anchor is placed into the prepared hole to secure the suture tapes. The laser line feature on the SwiveLock shaft can be utilized to confirm when the anchor is flush, or two millimeters countersunk. The same steps are repeated for the suture tapes on the contralateral side. The incision is closed. Jumpstart antimicrobial dressing can be utilized and the result is a secure knotless repair of the Achilles tendon rupture.

Achilles Midsubstance SpeedBridge™ Surgical Technique

This animation reviews the features and benefits of the FibuLock® PRO nail system, including longer-length nails, headless cortical screws, color-coded instrumentation, and a new modular jig.

What's NewJUL 30

SpeedPearl: Opening the CuffMend™ Graft Spreader in a Tight Space

What’s New This Week and Prior

JUL 29

Endoscopic Approach to Lateral Recess Decompression

JUL 28

BoneSync™ Bone Void Fillers for Proximal Tibia Fracture Management

JUL 27

Osteochondral Lesion Treatment With the 20 mm Precut OATS® Kit

JUL 26

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

Procedure

Product

Medical Education

Corporate

Resources

Patient

Careers

What's NewJUL 30

SpeedPearl: Opening the CuffMend™ Graft Spreader in a Tight Space

What’s New This Week and Prior

JUL 29

Endoscopic Approach to Lateral Recess Decompression

JUL 28

BoneSync™ Bone Void Fillers for Proximal Tibia Fracture Management

JUL 27

Osteochondral Lesion Treatment With the 20 mm Precut OATS® Kit

JUL 26

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

NanoNeedle™ Scope 2.0 Gains National Spotlight Through

Star MLB Pitcher's Recovery

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Product

Product

Medical Education

Medical Education

Corporate

Corporate

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Resources

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Patient

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Careers