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At the Orthopedic Trauma Fellowship Forum, Jack W. Weick, MD (Columbus, OH), presents an overview of the indications, operative setup, and surgical approaches for scapular fixation.

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Scapular Fixation for Scapula Fractures

OrthoPedia: Scapular Fixation for Scapula Fractures

Michael A. Gallizzi, MD (Vail, CO), discusses a salvage medial branch transection (MBT) procedure as a definitive solution for a 36-year-old female with right-sided low-back pain after two previous rounds of radiofrequency ablation provided only temporary relief.

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MBT as a Definitive Solution After Temporary Relief From Radiofrequency Ablation

As a medial branch. Transection procedure continues to grow in popularity. More and more patients are going to present to your office that have had previous radiofrequency ablation. That may not have lasted very long for them. So essentially, a lot of these patients will continue to have repetitive rfas, and their effectiveness continues to get shorter and shorter over time. But they still were effective for the time that they had the ablation. What a salvage medial branch transection can do is bring that effectiveness back to them as a definitive procedure for their back pain. Today, we're looking at a 36 year old female soccer player who had continuous right sided low back pain. She had two previous rounds of radiofrequency ablation. Unfortunately, the radiofrequency ablation on both of those rounds lasted less than three months, but it did hit the spot. Typically, these patients have had some success with the radiofrequency ablations. The pain relief just doesn't last. And for these patients, a salvage medial branch transection is a great option as a definitive procedure for their back pain. One thing to check radiographically with these patients is to make sure that they don't have any instability on flexion, extension, x rays, or any other contraindication that would tell us a medial branch transection shouldn't be performed for this patient. What I look for is patients that have a stable spine, with no evidence of slipping more than two millimeters on flexion extension x rays. The diagnosis for these patients has typically already been proven with successful medial branch blocks and or radiofrequency ablations that have treated that area, but the ablation has just not lasted. Many times, these patients have had multiple rfas over years and months, and they just keep going back for this short lived treatment. The revision medial branch transection is a great salvage procedure to be able to make that feeling of pain relief permanent. When I'm performing the treatment for a medial branch Transection revision. What I want to make sure you understand is how much scar tissue is going to be present from the previous radiofrequency ablations. The ablations have essentially caused a huge scar ball to form by that thermal injury to all the surrounding tissue. So really identifying the floor of the transverse process and moving out laterally to the accessory process as your lateral extent. Now what you're going to do is move both cranial and caudal on that transverse process to be able to start peeling back all that scar tissue. What you really want to avoid is going lateral to the accessory process, because in that area you're going to start getting the lateral branch that innervates the deep paraspinal musculature. You also want to avoid going to cranial or caudal, as we don't want to enter the neuro foramen, where the exiting nerve roots are coming out, as that can cause a neurologic injury. So being very careful on palpating and always making sure you're on bone is very important to a revision. Medial branch transection. Once your exposure is complete and you can adequately visualize the landmarks that we just discussed, what you really want to do is find that medial branch coursing out of the cranial neural foramen, down in between the accessory process and the lateral aspect of the facet joint. What you want to do next is find that branch, transect it with either punch or scissors to be able to completely renovate the medial branch, and then once that is complete, you take your high frequency RF probe and essentially denude all the neural tissue from the lateral facet wall all the way to the accessory process. This patient had an excellent clinical outcome since the two week post-operative period. They have been pain free, and she was able to return to all her mountain athletic activities without any recurrence in her pain. Postoperatively. What we do is we do put in some nylon sutures that we leave in for about two weeks. Well during that time period, we let them get back to their ADLs and walking, but really don't let them push any athletic activity. Once the sutures out and the skin has completely healed, we begin a scar massage routine in physical therapy to be able to get the soft tissue planes to slide. And then we get them into sports specific physical therapy as needed, to help them optimize whatever sport they want to get back to. Being able to offer your patients a salvage for a previous successful RFA that just isn't lasting, allows them to get back to their activities in less than two weeks. Really gives a motion preservation procedure that allows them to continue to avoid any talk of fusion. This is a low risk, high reward offering in the setting of a failed previous RFA and allows immediate return to sport and improvement of their spinal pain and low back pain without any talk of a spinal fusion.

MBT as a Definitive Solution After Temporary Relief From Radiofrequency Ablation

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

Patrick J. Denard, MD (Medford, OR), reviews recent literature regarding the efficacy of physical exams and MRI in recognizing subscapularis tears. He discusses two retrospective reviews of more than 800 patients demonstrating that subscapularis tears are difficult to detect accurately and consistently on physical exam and MRI. Therefore, it is important to confirm the integrity of the subscapularis arthroscopically, which is simplified with the ability to switch between 30, 70, and ultrawide view modes with the Pano™ scope and Synergy Vision™ system.
<a href="https://www.arthrex.com/resources/VID1-008215-en-US/subscapularis-tears-presentation-series-part-2-outcomes?objectID=human.resource.en.a6bc0eea-e870-43e1-b1a6-d5cab3cbad57.1&amp;queryID=27bd2007639c4606bae174e3be14f168">View Part 2: Outcomes</a>
<a href="https://www.arthrex.com/resources/VID1-008214-en-US/subscapularis-tears-presentation-series-part-3-predictive-healing-index?objectID=human.resource.en.b73b476b-cb6f-4a31-ba76-c04946ffe866.1&amp;queryID=b21ef7671e7ec60860e20c3c75d6ab8a">View Part 3: Predictive Healing Index</a>

Subscapularis Tears Presentation Series (Part 1): Recognition

Speaker  I'm Patrick Denard from Medford, Oregon. I want to share with you a couple of recent articles we've published on the recognition of Subscapularis teres, which point out some findings that I think will help you in your practice. The first study I want to share with you evaluated the bear hug test, and we compared that to the performance of a belly press test. This is a retrospective study of my patients over a ten year period. I want to point out, first of all, that in over 2000 rotator cuff tears, I found a subscapularis tear in about one third of cases. So it's important to note that prevalence. We correlated arthroscopic findings with the performance of the belly press and the bear hug tests, and compared that to a control group of over a couple of hundred patients. You see here this is the data looking at the sensitivity and specificity and performance of the tests. The overall sensitivity of this test is low. So you see that only about 50% of cases are we picking up a subscapularis tear with the bear hug test. Now the sensitivity of the test progresses as the tear size increases. But I want to point out to you that for type one tears or partial thickness tears, neither the bear hug or the belly press test is really going to pick up the majority of tears. Speaker  Once you get to full thickness tears, the performance really increases. In other words, what this means is that if you have a negative bear hug or belly press test, you really cannot rule out a subscapularis tear. You really have to rely on your arthroscopic findings. So your take homes here are. The Bear Hug test is twice as sensitive as the belly press test. The belly press test really does not add anything in terms of sensitivity. But still, many tears can be missed, especially for the partial thickness tears. You're really not going to get positive tests in the majority of cases until you get full thickness tears. So really, again, make sure you look at every case arthroscopically to confirm whether or not there is a subscapularis tear. In this next study, we compared the performance of radiologists to surgeons being me in identifying a subscapularis tear based on MRI. Again, we performed a retrospective review of over 800 subscapularis teres. We correlated MRI findings preoperatively by the radiologist or my interpretation with those arthroscopically, and also used a control group to make sure we were controlling for all factors. So this table here looks at the performance of radiologists compared to my interpretation of Subscapularis teres based on the MRI. Speaker  You can see that the radiologist missed about 50% of the tears. My performance was about 70% and that was based on having both the MRI with the examination and the clinical history of the patient at that time. One of the things that's important to note is similar to the performance of Bear Hug and belly press tests. The interpretation really gets better as the tear size increases. So for partial tears, both the radiologists and I missed many of those tears based on MRI. Once it got to a full thickness tear, I was able to pick up about 80% and that increased as tear size increased one once again. So the take home here is that radiologists only identify about 50% of subscapularis teres. Overall, you can see that surgeon accuracy is improved with the combination of having a high index of suspicion and be able to use the examination as well. So the real point here is that you cannot rely on the radiologist's interpretation alone. You have to make your own interpretation of that MRI. Combine that with physical examination findings. But yet once again, really make sure that you're confirming arthroscopically, especially for those partial tears that you're going to have a high chance of missing based on MRI alone.

Subscapularis Tears Presentation Series (Part 1): Recognition

Seth I. Gasser, MD (Tampa, FL), shares his firsthand experience with the Synergy Power™ system—highlighting how it streamlines workflow within a facility and why it is his preferred powered instrument solution in the OR.

Dr. Seth I. Gasser Surgeon Testimonial: Synergy Power™ System

Speaker  Energy. Power has really changed the way our team works and functions. It's streamlined the work process, including setup times and surgical times with just two hand pieces. It covers our broad range of needs throughout any procedure. It's reliable. Powerful. Versatile. The frequent changes required often during surgery are quick and easy, with a unique design of the hand pieces. It's very easy for the scrub tech to make a quick change. I don't worry about them having difficulty, and my focus is really on the surgery and the patient because I'm confident that the equipment will work as it's supposed to. It provides a balance of comfort and performance. It has a lighter feel. And it's the kind of comfort that really adds up over the course of long, difficult cases. Arthrex has been a leader and innovator as long as I've been in practice over the past 33 years. They've answered all of our questions, guided our setups, trained the staff, and really made sure everything ran smoothly before we started. And this is just another example of how Arthrex has made it easier for me as a surgeon to treat my patients better.

Dr. Seth I. Gasser Surgeon Testimonial: Synergy Power™ System

Paul J. Cagle, MD (New York, NY), demonstrates a tunnel-free acromioclavicular repair using the AC FiberTape® cerclage implant system.

AC Repair Using FiberTape® Cerclage

I'm Paul Cagle, a shoulder and elbow surgeon from New York City at Mount Sinai. Today we're going to talk about how to perform a tunnel less AC cerclage. Ac repair. As you'll see here, this is going to demonstrate a no tunnel technique where we're going to have no knots stack superiorly. Let's see how we got this done. This technique allows for a single mini-open approach. This is going to be approximately a three to 3.5cm incision that extends from the superior aspect of the coracoid roughly to approximately about the mid clavicle. And that allows exposure for both the coracoid passage and ultimately the clavicle passage. And this technique today we'll be demonstrating this without drilling any tunnels. So this will be a tunnel less approach. There's a layered exposure utilized for this technique. After our three centimeter incision we're going to identify our fascial planes, which you can see I'm grasping here. Typically a longitudinal opening is performed along the clavicle, which allows us to elevate and clear the clavicle so that we have access to the posterosuperior aspect of the clavicle for later passage. The corners of our deltoid are then elevated and a small T is created. You can see here that we've tagged those corners as I'll show you, and that's for later. Reapproximation and repair. This is the AC cerclage kit we're going to rely on for an AC repair or an AC reconstruction. Let's go through the contents. So here we have the contents of the AC cerclage kit laid out. And this kit really has everything you're going to need to tackle, even the simple or complex AC cerclage indications. And so we see we have two sutures here. One has a needle and one doesn't have a needle. And that really does come in handy sometimes in those areas that may be a little bit more difficult to pass, or be a little bit of a tighter space for your indications where you may choose to go transosseous with a button, the kit comes with a 2.4mm drill and a dogbone button, so the kit comes with convenient passes. Our Transosseous suture passer. Here there is a passer that utilizes a nitinol guide wire, and then we have a separate passer that's very helpful for getting around the clavicle. We have our mega loader, and conveniently that's going to come with a suture tape fiberlink as well as a tiger link. That way you can keep your sutures separate and identified if you're going to be passing a graft as well. When I go to pass a graft, I do like to dilate or make sure I have the space to get that graft around my coracoid and around my clavicle. And the dilating passer here will help you do that without a lot of extra dissection. Finally, the single use tensioner is going to be used today to get that reduction to hold it and ultimately get our alignment in the AC joint. So now let's head over to the patient and fix the pathology. Because this patient's habitus we're going to utilize the smaller passer. And we're going to go from medial to lateral for safety. So here we're going to pass this from medial to lateral. And many times we can use an army to simply expose that aspect laterally. And we're going to wiggle this through until we're through the soft tissue. And then advanced our suture which is going to be used for ultimate passing. In the occasion you need additional clearance around our coracoid we can utilize a dilator, and this dilator is going to provide increased clearance and clearance around the medial and lateral aspect. So in this case we will again pass from medial to lateral. I'm going to pass our dilator. And that demonstrates easy passage around our coracoid. Our dilator then can act as the final suture passer. And so we're going to take now our cerclage suture. We're going to pass this through our dilator and pass this again for safety purposes. Medial to lateral. The next step is to pass the end of our cerclage around the clavicle. It's important to pass this from anterosuperior to posteroinferior. That allows the suture to come out inferior to the clavicle, placing the knot inferior, decreasing the risk of soft tissue irritation. Again, the clavicle passer here is an opportune instrument to pass the suture. We'll identify our clavicle. We're going to pass our suture. Around. As you can see, we're going to wiggle this free until some of that soft tissue is off of our instrument. We'll then take our end of our suture. We're going to pass this through. And that will again pass. So ultimately the knot is going to be inferior to the clavicle. At this point we need to ensure that this is shuttled. And so we're going to carefully reduce this so that we bring the knot mechanism as close to the patient as possible. And we'd like to make sure the tension on the sutures is equal. As you can see, we're going to work a little bit of that slack out here. And it gives us excellent control of our clavicle. Next we'll simply pass our suture. And this is going to be reduced to the pre-tied knot mechanism. And again, it is nice to be able to get the slack out of this system and to reduce this along the inferior clavicle, as we're seeing here. Now, at this point in time, I sort of consider this procedure almost done, because the tensioning device we're going to use next is ultimately going to assist us in providing our final reduction. We now have our tensioning device. We will take one limb of the suture and pass it through the eyelet. And the second limb of the suture is going to pass just directly adjacent to this. And this is going to be brought directly down onto the knot. At this point in time you would like to obtain. A good tight fixation. And so we're going to tension these. Each sequentially on each side. And now we're going to just make small turns. And it's important to keep an eye on your clavicle and your construct to ensure you're watching your reduction as this goes. We'll see. Here is there's demarcations along the back of our tensioning device. And you can see as we release tension, those go in. As we increase tension we'll see our second line. The majority of the time to obtain good AC joint reduction, we are typically going to get to roughly our fourth line. We're going to continue to attention here. As you can see, we're getting close to the fourth line here. And we'll see now is we now have rigid reduction of our AC joint. Sometimes, as we can see here, there's a bit of soft tissue creep that occurs as that suture compresses along the periosteal surface of the bones. It's important to identify that because you're going to want to get that extra quarter turn or half a turn to make up for that compression from the very rigid fixation the AC cerclage allows. So next we're going to take our sutures off, and we're going to throw a half hitch not to tension this down. We'll bring. It's important to unscrew our tensioning device because that allows us to regain our tension. We'll slide back. We are going to throw a half hitch, and then this becomes an extremely elegant tensioning knot pusher. I'm going to bring this down here. We'll bring this directly adjacent. And again we simply repeat the steps of tensioning again ensuring that we have good wrap on each side so that there is ideal tension. Now at this point in time our fixation is done. We can back this up with numerous series of half hitch nuts given, as you see, that suture has brought our not far inferior to the clavicle. At this point we would simply cut. We've obtained our reduction.

AC Repair Using FiberTape® Cerclage

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

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

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

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

This video provides an overview of relevant peripheral nerve anatomy, as it pertains to peripheral nerve injuries.

Anatomy of Peripheral Nerve Injuries

OrthoPedia: Anatomy of Peripheral Nerve Injuries

The PARS system is designed for a minimally invasive surgical repair of an Achilles tendon rupture. It features an anatomic contoured jig designed to fit within the paratenon. The PARS kit contains collagen-coated 1.3 mm SutureTape with new differentiating colors and PARS needles that are used to create strong percutaneous locking sutures on the distal and proximal ends of the Achilles tendon.

PARS Achilles Jig System

When using the percutaneous Achilles repair system, a small 1.5 to 2 centimeter 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 pass 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. Pass the blue SutureTape under and around both green and white. Fiberlink sutures 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. The proximal suture tapes are moved away from the rupture site, and the jig is then inserted distally and the SutureTape passing steps are repeated. Once the jig is removed, three suture tapes remain on each side, both proximal and distal, ready for re approximation of the tendon to complete the repair. The foot is placed in maximal plantar flexion, and the black suture tapes are tied first on both sides. 3 to 4 surgeon's knots are recommended. Next, the blue locked suture tapes are tied, followed by the white suture tapes completing the repair. The incision is closed. Jumpstart antimicrobial dressing can be utilized and the result is a secure repair of the Achilles tendon rupture.

PARS Achilles Jig System

This animation highlights the unique features and benefits of the Arthrex Tibial Nail System and its comprehensive instrumentation. Engineered for a streamlined para- or suprapatellar technique, the Arthrex tibial nail’s innovative design enables treatment of extremely distal tibial fracture patterns.&nbsp;

Arthrex Tibial Nail System: Features and Benefits

Arthrex Tibial Nail System: Features and Benefits

The ACP Max™ system provides efficient concentration of platelets and growth factors from platelet-rich plasma (PRP) for use at the patient’s point of care. Expanding on the previous generation of PRP devices, the ACP Max system allows for a larger blood draw and provides increased platelet concentration using a unique double-syringe, double-spin design.&nbsp;

ACP Max™ Platelet-Rich Plasma System

ACP Max™ Platelet-Rich Plasma System

The Univers Apex OptiFit™ system represents the evolution of our stemmed anatomic systems.

Univers Apex OptiFit™ Surgical Technique

The humeral osteotomy is performed by either a freehand cut or with an intramedullary or extramedullary guide provided in the instrument set, taking care to maintain the patient's native articular inclination inversion. The Universe Apex OptiFit instrument set contains reamers and broaches designed to prepare the Intramedullary canal to match the stem's smaller footprint to minimize bone removal. The initial broach has an attachable version guide and version rods for proper broach orientation relative to the osteotomy broach until rotational stability is achieved and the appropriate laser marking is flush with the cut surface. Following canal preparation, a proximal humerus Protector is placed and attention is turned to glenoid preparation. There are three glenoid implants available. The universal glenoid convertible base plate. The keeled glenoid. And the VaultLock glenoid, which provides immediate press fit fixation on the central peg. The VaultLock is demonstrated here. A pin is placed in the center of the glenoid by using the pin guide. The appropriately sized VaultLock reamer is positioned over the pin, and the glenoid surface is then contoured to support the polyethylene component. The central hole is drilled with a six millimeter cannulated drill, stopping once the collar comes in contact with the glenoid surface. The glenoid drill guide is positioned by placing the central peg into the previously drilled hole. A short six millimeter drill bit is used to drill the superior peg hole. It's left in place to stabilize the guide for inferior drilling. The inferior 4.5mm drill bit is then used to prepare for the inferior keel. The glenoid brooch finalizes inferior keel. Preparation. Alternatively, the glenoid punch can be used with attention to impact just so the shoulder is flush with the reamed surface. Translucent glenoid trials are available. These provide visualization for the reamed surface while evaluating the proper orientation and fit prior to cementing the polyethylene component. The glenoid vault is cleansed and dried, followed by cement injection in the superior and inferior peg holes. A pressurizing tool is available for displacing cement throughout the vault. Bone graft can be used on the central peg. Autograft can be obtained from the native humeral head by creating a slurry with the bone graft reamer. The slurry is then placed into the graft compression tool, which is clamped around the central peg. Carefully spinning. The glenoid component on the grafting tool compresses the bone graft into the flutes of the central peg. Alternatively, a demineralized bone matrix product can be used for grafting the central peg. The VaultLock glenoid is then impacted into place. Attention is turned back to the humerus for stem implantation. The OptiFit stem has suture holes in the proximal body for soft tissue repair and subscapularis closure. The apex subscapularis repair technique takes advantage of these holes. Two holes are drilled vertically in the biceps groove for passage of the lateral suture. Limbs two. Number two FiberWire. Sutures are passed through the lateral holes, yielding four suture limbs labeled A through D from superior to inferior. A blue suture is used superiorly and TigerWire inferiorly for number two. Fiberwire sutures are passed through the medial holes, yielding eight suture limbs, labeled one through eight from superior to inferior. Blue and TigerWire. Sutures are alternated from lateral to medial limbs. C and d are passed through the inferior hole from the intramedullary canal out. Similarly, limbs A and B are passed through the superior hole from the Intramedullary canal out. All strands are held out to length on tension as the stem is impacted. Using the pointed stem impactor, followed by the angled Morse taper stem impactor, placing the trunnion flush to the osteotomy surface. The inclination inferior and version superior screws are then tightened with the torque driver. Trailheads are available to verify proper head size, head offset, shoulder motion, and stability prior to impacting the Definitiv head component. Suture limbs one through eight are evenly placed through the medial aspect of the subscapularis tendon. From superior to inferior. Your proper spacing is key to the final repair. The sutures are then tied in the following sequence one to A, eight to D, four to C. Five to B, 2 to 3 and 6 to 7. The suture color pattern is such that the first four knots are tied between similar colors, and the last two knots are tied between different colors. In addition, the last two knots are tensioned and create dynamic compression of the subscapularis tendon over the lesser tuberosity. The repair is then evaluated by externally rotating the arm with the arm abducted. The degree of external rotation achieved without stressing the repair is noted for postoperative therapy limitations. The wound is irrigated and superficial closure is performed according to the surgeon's protocol.

Univers Apex OptiFit™ Surgical Technique

This animation highlights the features and clinical applications of the ApolloRF® H50 probe, anatomically engineered for precision in the hip, with efficient tissue ablation and coagulation.

ApolloRF® H50 Probe

ApolloRF® H50 Probe

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.

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