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Pitcher's Recovery

Alan A. MacGill, DPM (Coral Springs, FL), reviews current literature surrounding lateral ankle instability treatments and discusses the significance of global ankle instability evaluation and management when treating ankle instability.

Foot and Ankle

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Lateral Ankle Instability: Literature Review on Lateral Ankle Instability Treatments and Global Ankle Instability Considerations

OrthoPedia: Lateral Ankle Instability: Literature Review on Lateral Ankle Instability Treatments and Global Ankle Instability Considerations

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.

Imaging and Resection

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ApolloRF® H50 Probe

ApolloRF® H50&nbsp;Probe

This animation outlines the steps for safely entering the joint using the Atraumatic Hip Access Disposable Kit.

Hip Joint Access Using the Atraumatic Hip Access Disposable Kit

The soft plastic material of the flush fit, a traumatic cannula system, and the blunt tip of the SafeCut. Capsulotomy blades are designed to reduce the risk of iatrogenic damage during access into the hip joint during hip arthroscopy procedures. Once the hip is distracted, insert a spinal needle and nitinol wire through an anterolateral portal to begin access into the joint. Use an obturator to dilate the capsule before inserting the plastic cannula. Insert the plastic obturator through the cannula by engaging the button, and place it over top of the nitinol wire with a slow, twisting motion. Depress the button behind the laser line and remove the obturator from the joint. Insert the NanoScope and bridge through the cannula to begin viewing the joint. Establish the mid anterior portal using the same steps used for the anterolateral portal to begin preparation for making a capsulotomy. Place the SafeCut blade through the cannula to begin the capsulotomy. The blunt end protects the cartilage from being inadvertently struck. Once the capsulotomy is achieved, replace the cannula through the incision to switch portals. Push behind the laser line to disengage the bridge from the scope and switch it to the mid anterior portal. Insert the blade through the anterolateral portal to complete the rest of the capsulotomy. The blunt tipped SafeCut blades come in straight and curved options with and without a handle, offering unparalleled versatility for safe joint entry.

Hip Joint Access Using the Atraumatic Hip Access Disposable Kit

Asif M. Ilyas, MD (Philadelphia, PA), presents a wide-awake endoscopic carpal tunnel release case using the NanoScopic™ release system.

Hand and Wrist

Wide-Awake Endoscopic Carpal Tunnel Release Using the NanoScopic™ Release Disposable System

In this video, we're going to be going through an endoscopic carpal tunnel release using the Arthrex Nanoscope system. This is typically how I'll prep a patient with the arm just kind of out by their side. My patients are awake, so I'm often talking to them during the surgery, just kind of letting them know what I'll be doing. Generally, I will before we even get into the procedure room or the operating room, I'll inject in the preoperative holding area. And what I generally inject with is nine CCS of 1% lidocaine with epinephrine. But then I also add a cc of bicarbonate to that injection in pre-op. And I usually use a 27 gauge needle. And the logic behind that is that the bicarbonate cuts down on the acidity of the lidocaine so it doesn't burn as much. And the 27 gauge needle obviously is a smaller needle, so it's much more comfortable for the patient. That's my initial injection, which I'll replicate here. But then when we start in the in the operating room, I'll then add another ten ccs of 1% lidocaine as well with epinephrine. And so I'll generally have about 20 ccs injected. And I'll inject that while we're in the room once we're prepped and draped before we start. So that I can both augment the the anesthesia and the surgical site, but also to check to make sure that the patient is adequately anesthetized before we start the procedure. So again this is a 1% lidocaine with epi with the assumption I've already injected ten ccs preoperatively in terms of prepping and draping, I do a standard prepping and draping where we'll do a wash in preoperative holding, and then we'll do a chloraprep in the operating room. Standard drapes as applied here. But again the patient's awake so we don't cover them. So we just kind of put the drapes around them. They can engage or not engage during the procedure as they wish. Some patients wash, some patients don't. If they do watch, they often just watch the screen where we're doing the release in. In terms of the injection, this is important. So doing an effective injection for a case that's wide awake is central to the process. So one of the first things is to make sure that we inject the the proper site. So there's a couple of ways to identify where to place your incision. So first of all it's an endoscopic incision. So it's going to be a transverse incision. Now a couple of things to keep in mind. One is the risk crease which is approximately here we generally want to go half a centimeter or so proximal to that. And oftentimes patients have a nice risk crease right here just like this individual does. And then in terms of centering it we want to center it with either on over top of the palmaris longus tendon if we can see it, or in line with the third webspace of the of the hand, or sometimes just just checking for what we call the inner Thenar valley. So it's a rough rule of thumb, but that's ballpark where you want to center it. So if you look here, if you palpate the FCR tendon, the FCR tendon is easy to palpate. That's more radial. And the palmaris tendon is usually harder to palpate. Now if the patient's awake you can have them have them touch their thumb and small finger, and it'll bring the palmaris to the surface. Broadly, though, it's it's a central incision. So seeing here, here is that wrist. I'd like to exploit. It's about a one centimetre incision or about a half an inch incision transversely. Okay. So I'm going to mark it out some more. Again this should be centered above at the level of the palmaris longus or in line with the third webspace or in line with the inner thenar valley. So very simple. If anything, you're cheating. Slightly midline to ulnar is kind of the broad rule of thumb. Now, in terms of the injection, I'm going to place the injection here like I would in preoperative holding. So what I typically do is start the injection out to the side and outside the level of the hand. The hand is most sensitive. So we're at the wrist level here. Enter slowly. And the key is to enter and then inject slowly. Now the 27 gauge needle allows us to inject slowly because the needle is so small. And you'll notice I don't move the needle a whole lot. I'll inject 2 to 3 ccs right where I entered, and you'll see where insufflating the area where the incision is. Then that's the last time I'm going to enter a virgin territory. Now, going forward, I'll always enter where I've previously injected. So now I'm going to inject proximally. And I'm mostly superficial with this. And I'm injecting proximally. Now, as I do a little bit more proximal, I'll then go a little bit deeper slowly to get the median nerve as well. So I'm now below the antebrachial fascia. Then I do my distal injection where again I'm going to inject through area I've previously injected. And I always inject slowly. So I always make sure that the injection is going ahead. The flu is going ahead of my needle, and I'll put a finger here just to make sure that I'm getting adequate anesthesia distally. Obviously I don't want to put a needle in my own finger, but I'm making sure that I have enough volume distally. And that's the injection that I do in preoperative holding. And I'm going to do the same injection before we start. And and as we're doing this, I'll ask the patient, are you feeling any of this and make sure that we're adequately covered the area with the local injection. So I find that 20 works well, ten in pre-op, ten during the procedure. So once adequately anesthetized we'll start. So the incision is a transverse incision. So anytime you're placing a transverse incision across any limb you want to be very careful. You don't want to cut structures right. So you want to be very ginger in terms of your depth of your blade. So we're going very slowly. The structure most at risk with this approach here is the palmaris longus. And just below palmaris longus is going to be our median nerve. So we want to be very careful with that. So we don't want to be too aggressive. And we want to then bluntly dissect. So we're going to keep doing this until I see the palmaris longus tendon. Now, you should note that 10% of people don't have a palmaris longus tendon. So there are times where you'll do this and you will not find the palmaris longus tendon. And that's okay. But broadly, that's what we're going for. First is to find that palmaris longus tendon. And you'll notice I'm not cutting anything here because you can potentially come across branches of the palmar cutaneous nerve. So we want to be very ginger with that. Generally as I'm doing this I'm I'm talking to the patient as well. At this level, most patients don't have much discomfort. It's when you get a little bit deeper that they might notice. But I want you to notice at this point here is that we've got our antebrachial fascia exposed. If a palmaris is present, we'll place a ragnell on this side to retract that. So this goes that ragnell goes on the radial side to retract that. And then the skin hook is elevating distally. And what you'll see is a clean view of the antebrachial fascia, which is confluent with the transverse carpal ligament or the carpal tunnel ligament. All right. So once we're here, you can either a transversely cut the antebrachial fascia with a blade. Or in this case what I'm going to do is I'm just going to poke through gingerly with my tenotomy scissors. Like so. And you want to give this a good stretch because this can be a kind of a choke point, if you will. If it's not adequately released when we introduce the scope. And then we'll bring our double skin hook to elevate and grab the the distal part of the antebrachial fascia. So once we're through the antebrachial fascia I should be able to see the median nerve. So if you look here, that structure that's directly evident is actually the median nerve right here. So we're actually seeing the nerve right in our field immediately. And at this point, we can start to prepare the canal and introduce the nanoscope. At this point, I'll usually have my team open up the Arthrex system, which has two boxes, one has a nanoscope, one has the trocar and this dilator. And this side you'll see the synovial scraper. And this side here is the dilator. Okay. So we're going to first enter with the dilator. Now if you feel like it's a tight canal you can first enter with the freer. So just to show that we'll do that here. And I always put a finger at the distal end of the carpal tunnel so that I know what I'm aiming towards with my other hand. And sometimes there's some tissue here. So the freer sometimes is a little bit less traumatic. So we'll enter with that until I'm confident we can get in there easily which we can. So that was the freer. Now I'm going to enter with the dilator okay. So the dilator. Yep. There we go again. My fingers where we want to go. And we go slowly here because this is dilating the canal. This can be sensitive in patients. So I go slowly. I don't jam it in there. So I kind of nice and slow. We kind of come back a little bit just to kind of make sure it's nice and comfortable, and I always prepare the patient for the next minute or two. You're going to feel a lot of pressure because frankly, it only takes a minute or two to dilate and then to do the release from this point. But this is the point where they're going to feel the most. And so you want to prepare them for that. So again, you're going to feel a lot of pressure here. And like so once you're adequately in there then we'll go to the other side which is the scraper. And this helps to clear the undersurface of the transverse carpal ligament of any synovial tissue. So you have a nice clean look at the transverse carpal ligament. And we're looking for those transverse fibers once we enter the actual nanoscope. So here's our carpal tunnel release handpiece. So this is one of the instruments that we're going to be using to put together our release system. And this is the nano needle scope. And before we take off this rubber eyelet, we first calibrate it, which requires, once it's plugged into the console, simply pushing either button and it will calibrate the nano needle. You'll get a very clear green mark saying that it's been calibrated. Once that's done, you can take off the the cover. Once we take the eyelet off, we just introduce the nano needle into the handpiece and there's a little bit of play. You got to give it a little bit of a push. And then at the end it clicks in place. One of the things that's different about this than, say, a traditional scope is that this black part of the nanoscope right here is what controls your orientation of your screen. So oftentimes people will rotate their handle to get an up and down. But you want to actually make sure that this part here the nanoscope is centered and oriented parallel to the handpiece. Once we have that we're all inserted. Just taking a look at this, you'll see that there's a blade inside of the handpiece. And this lever here. When we push this, it deploys it, and you'll see how that blade deploys. When I let go of the lever, the blade retracts. So it's a nice system in that you'll only deploy the blade when you're actually pushing this lever. Otherwise the blade returns, and that creates a more safe cutting environment. The other thing is that this technique and this system use a retrograde cutting design, which I think is a safer way to cut. So you're always seeing what you're cutting, in contrast to the integrated cutting designs that are more of a push blade, where you're not seeing what you're cutting until it's cut. So let's introduce this. So now we've finished dilating, we've put together our nanoscope, and now we're introducing this in. And again we're going to follow the path that we created. It should go generally easily some of the times when it doesn't. The primary reason is that we haven't dilated enough, or the opening in the antebrachial fascia is too tight. So once we introduce the nanoscope and the carpal tunnel handpiece, one of the questions is often how deep to place this. So I'll generally place my finger at the distal end of the carpal tunnel as demonstrated here. There's also you'll notice that the handpiece is calibrated and you'll see numbers. You'll see a three and four showing here. Generally it's rarely passed to three and almost never passed to four. In terms of the depth. And that matters because if you're too deep, you could potentially injure the palmar arch. So placing both the finger distally and making sure you're okay from a depth perception is important. The other thing, as mentioned previously, is again, we want to make sure our camera orientation is right. So sometimes if the camera the nanoscope inside the handpiece is rotating, you might get a view like this. And then you may be tempted to rotate your nanoscope around to get a better view, and then it'll cause an obliquity with which you'll cut the ligament with the blade. So again, make sure that you're up and down with the nano needle in the handpiece as demonstrated here. Once you're satisfied and you know where you're at, you can deploy your blade. I generally recommend going a little bit at a time, a little bit of downward pressure again with that same digit that is identifying the distal end is helpful. If you'll notice here, you'll see that we're right where we need to be, because you'll see there's a clean line at the end of the ligament. And you'll see the transverse fibers that you're cutting as well. You obviously, most importantly want to make sure that there's no parallel structures that are in your field above you. The big thing that we always worry about is potentially the median nerve flipping up and being superficial to the handpiece and the blade. So you should only see these white transverse fibers coming across. And then you can deploy it as mentioned and start releasing. I'll do a little bit at a time where I'm deploying pulling back, and I'll drive the camera back in. And I want to see muscle and or fat pooching through and no transverse fibers when there's no transverse fibers and only muscle or fat pushing through. I know that we've released it. I do a little bit of time again. You'll see. Just muscle falling through. No transverse fibers. I'll deploy it one more time just to make sure. And you'll notice there's nothing there. And there's no feedback either relative to the blade as well. And before you exit, you want to make sure that your assistant has that skin hook on the skin. Because it is it is easy to cut the skin on the way out. So as long as you are retracting that skin with that double skin hook, you should be safe and exit and finish your release like so. At this point, you're done with your endoscopic release. Once the endoscope is out, it's still important to take a look inside and make sure that you can see the two leaflets have been released. I'll often move the retractor more superficially so as to see the antebrachial fascia a little bit better and make sure that I'm adequately released distally. If there's any residual transverse fibers at this point, you can obviously release them as well. Once satisfied, we'll take this double skin hook and we'll switch the position to this side. And then we're going to release the antebrachial fascia proximally. So you'll see the antebrachial fascia right here. I'm not going to do a slide I'm going to first make sure that I have enough dissection proximally to make sure that I'm in a safe place. And then I will go ahead and release the transverse fibers. I'm always raising my hand as I do this, and you'll see that the antebrachial fascia, approximately has been released as well, at least a centimeter or two. And here you can see the median nerve directly released, uninjured and directly in your view. Once satisfied with the release, I wash and close in standard fashion. Nothing too fancy. I typically use a dissolvable suture. In this case, we're using a prolene suture to close. Simple. Put a light dressing on and then send the patient on their way. My post-op instructions include keeping the dressing on for a couple of days. After a couple of days of dressing can be removed, they can shower, wash normally, everything can get wet and I use a dissolvable suture which the regular bathing helps to dissolve away. I typically don't require any therapy unless there's an issue, and I let them wean back to their activities as tolerated. I always advise that to take it slow the first couple of weeks, some amount of swelling or soreness can linger for about 2 to 6 weeks, but again, mostly common sense restrictions. A few tips and tricks to keep in mind when you're starting this out, particularly if you're doing this in the office setting. Doing this without a tourniquet can be challenging, and I think it's reasonable to use a tourniquet until you're comfortable with the technique and the visualization. It's a much bloodier field when you're not using a tourniquet, and tourniquets can be uncomfortable for the patient. A couple other things to keep in mind in terms of tips and tricks is avoiding sliding proximally. So that last part, you might have noticed that I released the antebrachial fascia. It's tempting to just slide your tenotomy proximally, but the median nerve is very superficial at that level, so elevating, visualizing, and then releasing that antebrachial fascia proximally is a safer way to go. The other thing I would tell you in terms of doing these cases awake, is that sometimes people have varying responses to the local anesthetic, and if I feel like they're not getting a good response to the lidocaine, I'll then use a different agent, like a marcaine, and sometimes a different class of local anesthetic additively can help make a difference as well. There's a number of really unique advantages to the arthrex and nano endoscopic carpal tunnel release system. We've touched on a few of them, but just in summary, one is the simplicity of the set and the design. Two simple boxes the nano needle inserts into the handpiece. It has a clear cannula which increases your visualization of your field during the release. You've got a sharp retrograde cutting blade, which is a safer cutting style, and it keeps and allows you maximal control. But perhaps the most significant aspect of this is the fact that this system is not reliant on using a traditional scope tower. So this allows you to do these procedures anywhere. It could be in the hospital, it can be in an ASC, but also it can now be done in your office because all you need is a console and you are no longer are required to have a large scope tower and its associated heavy equipment in order to do an endoscopic carpal tunnel release.

Wide-Awake Endoscopic Carpal Tunnel Release Using the NanoScopic™ Release Disposable System

Erik Kubiak, MD (Las Vegas, NV), delivers a modern take on cerclage fracture management. He addresses the common challenges with traditional cerclage cables and the evolution of nonmetallic techniques. Part of this evolution is the development of radiopaque FiberTape® cerclage, and Dr. Kubiak presents cases highlighting the use and benefits of this technology.

Cardiothoracic Surgery

Shoulder

A Modern Take on Cerclage With Radiopaque FiberTape® Cerclage

Kubiak from Las Vegas, Nevada. Here to give a modern take on cerclage technique. Cerclage cables in any application of trauma have always sort of carried the concerns about breakage of implants. Issues with fracture security, metal fretting, potential vascular injury as a result of these sharp metal fragments injuring vessels and the proximity, and then particularly in the proximal femur. Third body where where you have little bits of metal from the broken cerclage cables involving themselves or wandering into the articular surface of the hip. Classically, these techniques are used like this to secure the femur, particularly in periprosthetic settings or in implant revision settings. We've sort of struggled with the metal implants and have evolved over the last 20 years to using polymer implants. The first of these was a nylon polymer implant with a polyethylene core. We've really moved away from that implant to a uhmwpe fiber tape implant. Issues with that fiber tape implant on initial presentation, where not everyone was comfortable with an implant they could not see radiographically. Henceforth, the development of a bismuth trioxide impregnated uhmwpe implant, which is radiopaque and leaves evidence of the surgeons activity on radiographs. Postoperatively. Issues with fracture security as demonstrated by the old metal implants. An evolution of that technique to a oraf dominant fixation construct, where the cerclage cables are used for provisional fixation, which is kind of where we've gone. And again, issues with potential metal dissimilarity. The cerclage cable versus the plate, and again, not free of the risks of breakage. And the third body migration into the articular surface. This is the bismuth impregnated uhmwpe material recognizable by its yellow color. And in this circumstance used to reconstruct after a clamshell osteotomy for a Vancouver B periprosthetic femur fracture complex. Periarticular trochanteric femur fracture. Not really amenable to oraf. Raf going to be treated with a total joint arthroplasty. This is the case where we used the cerclage cables to reconstruct the femur around an implant. And as evidenced on these fluoro images, you can see the radiopaque cerclage material quite readily on multiple views of this femur. And then this person, due to some GI distress, ended up with a CT scan almost three months later. And you can see that the cerclage cables are readily apparent on the CT scan as well. Another case 78 year old female poor bone quality sick patient. Pre-existing hip osteoarthritis, which necessitated a total hip arthroplasty. You can see here as circled the presence of the radiopaque cerclage cable fiber tape around the proximal femur. And then on the post-op films on the post-op plain films, again, the readily apparent cerclage cable fiber tape in its location were placed still secure at three months. More and more frequently, we see periprosthetic fracture around the proximal humerus. This is often a almost a more difficult situation than the femur because the bone quality is so poor. We're working to find improved fixation techniques to maintain stability of these fractures and allow patients to regain function in their arm and try to restore bone stock. And these circumstances were now sort of evolved to using allograft bone struts with multiple cerclage tapes for fixation allograft strut prepared with grooves to maintain the position of the cerclage cables when passed, and then application of those as seen in these fluoro images you can see there, they're readily apparent radiopaque fiber tapes or collage around the implant, both in the fluoro and in the post-op period, as evidenced here in these plain films. The evolution of this suture material going from a fiber tape cerclage to a fiber spacer collage with its now radiopaque, it results in the same strong fixation readily visible on fluoro radiographs and CT. It has the advantage of being retention able with little to no concern of third body wear, and it's easy on the bone. We don't see the subsurface resorption that we did with the nylon polymer constructs. Thank you.

A Modern Take on Cerclage With Radiopaque FiberTape® Cerclage

Expanding on the trusted Syndesmosis TightRope® platform, the Syndesmosis TightRope PRO implant is the next generation in syndesmotic fixation. Updated instrumentation and lower-profile implants provide efficiency by design, enabling effective treatment of syndesmotic injuries.

Experience the Syndesmosis TightRope® PRO Difference

Experience the Syndesmosis TightRope® PRO Difference

ApolloRF® H50 Probe

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.

Trauma Upper Extremities

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.

Spine

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.

Trauma Lower Extremities

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.

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