Aaron J. Krych, MD (Rochester, MN), demonstrates how to use a 3D-printed, patient-specific instrumentation (PSI) osteotomy guide with the iBalance® HTO system.

Knee

Human

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English  - en

video

iBalance® HTO Using Patient-Specific Osteotomy Instrumentation

Speaker  My name is Aaron Critch from Rochester, Minnesota, and I'm very excited today to demonstrate the Arthrex iBalance HTO patient specific instrumentation. So to demonstrate, we're going to first look at this three dimensional printed anatomic model. So this is a left knee. So here you can see our tibial tubercle. We're on the medial side of the knee. You can see the articular cartilage of the medial plateau and the medial side of this tibia. So we're going to first show you the guide in terms of how do we link the patient's anatomy to the HTO iBalance system. So this is custom printed from the patient's anatomy. And it contours extremely well. We want to find first that anatomic positioning where it locks in. So a couple landmarks here you can see on the tibial tubercle how it locks right in underneath. And you find the one and only stable spot where this guide is intended for this patient's anatomy. Once we have that spot, then we will convert and we'll use the iBalance HTO system for a completely instrumented osteotomy. So you can see we have our custom printed patient guide. And now we've coupled this to our iBalance HTO standard instrumentation. So we first find the stable position on the patient's anatomy, where we've customized this plan to our corrected plan for the osteotomy correction. So once this is in a secure location, we'll now fix it to the bone with these babies which do a really nice job of locking in this guide. Speaker  So it's completely stable. So we have two proximal fixation points and two distal. So once that's complete again this is completely stable On our osseous anatomy. So once we have the patient's guide connected securely to the bone. Now we're going to connect the standard iBalance HTO metal instrumentation guide. So we'll place a pin anteriorly in the front as we normally do. And then we'll place our second pin medially as we would normally do for the iBalance HTO instrumentation. So now that the hinge pin guide is in place, this was set to a medium to accommodate the patient's anatomy, per our preoperative plan. The. One of the advantages of this system is that Intraoperatively. We can change to a larger implant size if needed. So we'll take our hinge pin guide, and we can look to make sure that we have this closer to the lateral cortex than to the lateral plateau. We want this ratio to be at least 1.25 to 1. If you so desire, you could also take an X-ray, An AP X-ray straight down this guide to see exactly where this lines up. If for some reason you were not as close to the lateral cortex as you wanted, if you weren't at that 1.25 ratio. Now you can simply change this to a large size before we start drilling anything further. Speaker  So again, flexibility in the system to make some intraoperative adjustments per the patient's anatomy if needed. In this case, we like the medium. So we're going to lock that in. We're going to place our hinge pin guide down. And we're going to lock down that guide. And then we have our drill for our hinge pin. And we want to make sure that this is bicortical but that we're not going beyond the posterior cortex. So we'll first go through the anterior cortex. And then once we're through, we'll feel the cancellous bone, feel our posterior cortex, and then just pop through, taking care to protect the neurovascular structures behind. And notice the hinge pin here is completely from anterior to posterior. We want a nice lateral hinge. We don't want to create a posterolateral hinge and change our slope in the system. That's another advantage of this guide. So once we've drilled for hinge pin now we're going to place our hinge pin guide to maintain our hinge pin throughout the rest of the case. So this has a slot on it that will lock in for rotation. Once we have that we can then take our alignment mount off, and we'll replace our locking nut for the guide for the hinge pin. And then at this point we can uncouple the patient's custom guide. So we'll remove this portion and we'll remove our two proximal and our two distal BB-Tak. Speaker  And at this point, we are completely aligned from the patient's anatomy to the iBalance HTO system. Once we remove the patient guide completely, one important double check on this system is to make sure that this tab is right up against our Posteromedial tibia. And then you'll see this tab right in here also needs to be right up against bone. That ensures the bone that we remove for the peek implant will sit nice and flush inside of our cortical window that we make for the osteotomy. Once we've confirmed we're in the correct position, then we'll go ahead and ream our two pegs. So I like to ream anteriorly first, and then we can replace that with a peg to make sure nothing moves in the system. So then we can ream for our Posterior peg. And again, this is a positive stop. So we make sure we're all the way flush. And that will set us up for our next step, which is to place the cutting guide into the bone. So we'll use the screwdriver to remove this locking screw. And then we're going to place our cutting guide. At this point, you could save any autograft bone that you wanted to and use it as bone graft later in the procedure. So once we have our pegs reamed, we're now going to place our small medium cutting guide. Speaker  So that slips directly on and we're going to secure that with our screw up here. And then once we have our cutting guide in place, we're then going to place our neurovascular shield. So once our cutting guide is completely secure, then we'll take our neurovascular shield. Protector. This is the small medium. So we'll hug the back of the tibia. And you can kind of give this a little bit of a roll, and then we'll secure this neurovascular shield in place, which helps protect everything right behind our tibia. Once that's done, I will remove this handle to get it out of our way. And then now what we've done is we've completed our safety envelope. So you can see we have our hinge pin goes from front to back. So that's protecting our lateral hinge. We have our neurovascular shield going in the back to protect our neurovascular structures. And then this guide right here is to protect our patellar tendon. So when we use our saw blade, we have a complete envelope of safety when we perform this osteotomy. Okay. Now that we have our safety envelope completely assembled, now it's time to perform our osteotomy. And with this guide, we want to get all the way from anterior to posterior. We want to get all the way from medial to posterolateral and then all the way lateral. So we'll go ahead and complete the osteotomy. Speaker  Once we've completed the osteotomy with the saw. Then we can use our osteotomy. You know you really want to feel are we hitting metal again with our safety envelope really is a good indicator that our osteotomy is complete. So once our osteotomy is complete, we can then take our neurovascular shield and remove it. So we'll put the handle back on for our neurovascular shield. And then we'll take this neurovascular shield completely off. Usually when you have the soft tissues, it might require you just to wiggle it around to remove it. And then at this point we can remove our cutting guide. So we can take our cutting guide completely off. And then at this point, we can decide sometimes what I will do is I'll take my osteotomy, and I'll just double check before I remove everything that we have mobility in our osteotomy. And you can see here, this is exactly what I would want to see. It's nice and springy. We have a lateral hinge. This is going to be great for our opening wedge osteotomy correction. Once we've confirmed movement, then we'll remove the rest of the guide at this point so we can remove our hinge pin. And we can also remove our other two pins. And we're going to take everything off from our tibia and get ready for our next step. So at this point we will begin correcting and opening our osteotomy. Speaker  So this is our jack opener. We have it set to medium and it's lined up with the hinge pin. So one pearl to help line this jack opening guide up is we can actually use our peg to make sure that everything fits perfect. These flanges want to be right flush with the bone. And then we can just start gently opening it until our peg is loose. At this point, we'll use our angel wing. So we'll bring that in to measure. For this patient. We wanted a medium seven degree correction. So you can see the degrees here. Right now we're just at two degrees. And I'll open the osteotomy slowly a few degrees every 30s or so you can take your time. Opening the bone just depends a little bit on how easy it's opening. In this case, everything's opening very easily and we're preserving again that lateral hinge. So here again we're going to take this to our preoperative template, which for this patient again we wanted seven degree correction. So we're there. So at this point we can just take a look at everything clinically to make sure that we're happy with our preoperative plan. So here one pearl is that we can just open our osteotomy just a degree or two beyond our correction, and we slide our peak implant for iBalance osteotomy into place. Speaker  And at this point we want to remove the jack opener. So in this case I'll actually disassemble it. And you want to make sure that that plate stays in as you're taking this jack opener out. So you can either remove it in 1 or 2 pieces. And the key with this implant is that you want it flush with the bone, or even maybe a half a millimeter off the bone, but you never want to insert this implant. What's nice about this completely instrumented system is this will fit right exactly where we want it to, to get cortical support for the patient as they're beginning weight bearing rehabilitation. So we lightly tapped our implant into place. And you don't want to over insert it because you want the cortical bone support one pearl as I leave this about a half millimeter off the cortical edge, and our screws will actually bring it in flush. I like to place our proximal cancellous screws first. And the nice thing is we have a custom plan. So I already know that this posterior proximal is going to be 32mm. And the proximal anterior will be 24mm. So our guide has our numbers and we can read our depth right off of our guide. So we'll drill right to our line at 32. So now we'll place our two distal screws. And these are cortical these are bicortical screws. Speaker  So again from the preoperative template. I know that this one is going to be 34mm, so I just confirm that depth with my guide. And then the difference between our proximal cancellous screws is this one we will need to tap. And you want to make sure you tap to that second cortex and through that second cortex. So these peek screws can fit in nicely. So I feel that second cortex I get through it and then we'll place our bicortical screw. So now we've placed all four of our screws, our two proximal cancellous our two distal bicortical screws. The most important part when we're finished is we want this posteromedial part of the implant to be completely flush on that cortical bone. So in this specimen, this looks perfect. That means we've lined up our guide perfectly to mill for the implant that replaced the bone that we opened. In real life, we would place bone graft at this point in our osteotomy. So we would place some AlloSync Pure bone graft. And then you can see with our perfectly lateral from front to back, anterior to posterior hinge pin. This is a completely stable osteotomy. And you've got our nice peak implant that won't be painful. That won't be prominent for the patient. We've got a lot of tibial real estate to do combined procedures, ACL, PCL, root repair, etc. so overall an excellent system which was customized for this patient.

iBalance® HTO Using Patient-Specific Osteotomy Instrumentation

Noman A. Siddiqui, DPM (Baltimore, MD), presents a cadaveric demonstration of the Arthrex Beaming System for midfoot reconstruction. This video provides a step-bystep walkthrough of guidewire placement, implant selection, and beam insertion to restore a stable, plantigrade foot. Throughout the demonstration, Dr. Siddiqui shares procedural pearls, implant positioning strategies, and fluoroscopic guidance to help optimize fixation and attain reproducible outcomes.

Foot and Ankle

Arthrex Beaming System: Cadaveric Surgical Demonstration

Speaker  With the minimally invasive joint preparation complete, it is important to obtain your position for fixation. I first incorporate axial load on the first MTP joint that imparts stability along the medial column. Mis provides the soft tissue stability, and at this point, provisional fixation can easily maintain the correction for your definitive fixation. The key is to place these wires out of the path of the screws, and this can be done by adjusting the position of the wires in the intended path of the medial column. I like to plantarflex the first ray and adduct the medial column to make sure that the first ray lines up with the talus. At this stage, I'm going to take an AP view of the foot to ensure that this provisional fixation is not going to be in the path of my intended screw. As you can see, our temporary fixation might get in the path of the medial column beam. So I'll just still maintain that axial pressure and oscillate this wire out. I will redirect for this fixation to be slightly lateral. Once I'm satisfied with my position, I can tell on this radiograph that my AP is lined up nicely. The midfoot and hindfoot position are appropriate. Now I'm ready for my guide wires for screw fixation. At this stage, I want to identify the trajectory of my guide wire. I want to be on the medial side of the talus and through the cuneiform and near the mid-shaft of the first metatarsal. I do that by outlining my path on my guide wire, and this is a good landmark at this stage. Speaker  I will be entering the first metatarsal. As you can see, I'm in the mid shaft of the metatarsal, nearly bisecting the cuneiform crossing, the navicular, and on the medial third of that talar body and neck. Now, the placement of this wire can be done through a dorsal incision or a plantar incision. I prefer the planter. When I make this incision, I don't start directly at the level of the joint. I start at the level of the base of the proximal phalanx. That's usually the distal pole of my incision. And I'm identifying midline on the helix. Once the incision has been made, I dissect proximally to this level of the sesamoids. Here I'll bluntly with nick and spread technique, get down. Pass the flexor to the level of the articular surface. The most technically demanding portion of the procedure is accurate k-wire placement. Once you've entered the articular surface, you can adjust the trajectory of that guide wire by oscillating. Once you feel the wire fall into the shaft of the metatarsal, do not advance it any further and get an AP view to make sure you're heading down the bisection line of the metatarsal. At this step of the procedure, it is important to make sure your metatarsal wire is heading correctly into the cuneiform, the navicular, and into the talus. So in my mind's eye, I'll make sure that I adjust the wire at this step to make sure I'm going to engage the appropriate bones. I can see that I'm directed slightly medial, and this is where I can make these minor adjustments by oscillating. Speaker  Any small deviation at this point will have a significant impact at the final wire placement. Though the wires are designed to redirect, you can minimize the direction that they will deviate by just tapping the wire in the metatarsal. Once the metatarsal reached the base, take an X-ray and now you can be confident you're going to be bisecting the cuneiform into the navicular and then redirect into the talus. At this stage, I will transition to the lateral view. At this stage you can see we have entered the cuneiform near midline and we can be pretty confident. Now a technical tip. You want to be on the plantar medial side of the talus on a good healthy talus. So by any means necessary this is going to enter the body of the talus medially. I like to oscillate. Once I'm satisfied with the trajectory, I will deliver it completely. It is important to recognize that the tip of the wire is where the tip of the beam is going to end up. On the medial column, you want to engage as much of the body as you can, but leave yourself enough room to allow for your subtalar joint fixation. At this stage, I will be placing my subtalar joint wire and then followed by lateral column wire across the C-C joint. The sequence of wires is done this way. It allows you to stabilize the medial column, and then the calcaneus or the subtalar joint fusion with respect to the talus. Then finally, the lateral column is fixated to a stable medial column and a stable subtalar joint position. Speaker  I like to place all my wires first prior to placing my fixation. This allows me to respect the limited real estate available in the Talar body. The sequence of fixation follows the medial column, followed by the Subtalar joint, followed by the lateral column. The most important thing to remember is to rotate the midfoot prior to fixation. You cannot leave the first ray elevated. A transverse or a vertical incision can be made at the posterior one third of the tuber, and at this point I'm aiming for the posterior facet trying to be near perpendicular to the posterior facet with my wire placement. I place it initially. And here. Now I can adjust with my trajectory. Once I've bisected my posterior facet, I can use this position to place my lateral column wire. From a visual perspective, I utilize the center of the body of the calcaneus for my wire placement. And then as I advance it into the Talar body, I try to be in the middle one third for final fixation. At this stage, after you've confirmed the accurate position within the body of the talus, take a second to take an axial heel X-ray to make sure you like your position in the center of the calcaneus. This final lateral column fixation is placed through an incision somewhere between the third and fourth digit. I try to come a little distally and make it about a centimeter long, and then I place my wire through this incision. After bluntly dissecting down in between the interval of the metatarsal. Speaker  And to do this, you have to do this in the AP view, but you can start off in the lateral view with your wire placement. So the wire is carefully guided down to that inner space and an X-ray is obtained. So at this point you can advance that wire across the C-C joint. This wire is purposely placed in the interval between the bases of the metatarsals. It serves as a wedge and additional stability to this construct. At this stage, we can remove the provisional fixation prior to placing definitive fixation. At this stage, if you're satisfied with your wires, any provisional fixation can be removed, and the final step of adding biologics to this construct can be performed. The depth gauge is inserted over the k-wire and seated firmly against bone contact can be confirmed fluoroscopically, and then the length is read at the silver to gold transition on the depth gauge. Do not read the length from the back of the K-wires. As with legacy systems, and here it measures somewhere between 155 and 150. Because I'm going to seat this a little further into the head of the metatarsal. I'm going to ask for a 145 millimeter screw. The next step will be to drill. An important step in this aspect of the case is to make sure you drill into the body of the talus. It is not uncommon for the initial guide wire to come out after this step. At this step, the profile drill can be utilized to create a place for the head to be buried in the bone and soft bone. Speaker  The profile drill may be omitted, but in hard bone it should not be omitted to allow proper seating and reduce fracture risk. Okay. The beam is inserted under power. Therefore, you have to stabilize the foot as significant torque can be generated during advancement of this screw. Now this can be done with the first MTP joint. Dorsiflexed. While an assistant is stabilizing the midfoot. After the initial placement of the fixation, you should visualize compression across each joint. The dovetails at the tip of the screw allows for easy compression without a lot of stress for the surgeon, and the final compression can be achieved with the T-handle device. The screw is the subtalar joint screw. Again, you work it all the way down to the body. I look at the transition between the gold and the silver, and it measures approximately 95, because I'm going to be burying the head a little bit. I'm going to choose a 90 millimeter screw. A seven millimeter screw is going to be placed across the subtalar joint. The appropriate size drill and drill sleeve are being utilized. Final fixation is done with a T handle to get the accurate position. Lateral column screw. It's the surgeon's choice to profile drill this. I typically don't because I like it wedged between the metatarsals. You're going to start in the lateral view and then you're going to finish final positioning of this lateral screw in the AP view. This concludes the cadaveric demonstration of miss beam placement using the Arthrex beaming system.

Arthrex Beaming System: Cadaveric Surgical Demonstration

This animation demonstrates the features and benefits of the StayPort™ cannula for hip arthroscopy. This cannula is designed to enhance portal stability, streamline instrument management, and improve procedural efficiency during hip arthroscopy.

StayPort™ Hip Cannula

StayPort™ Hip Cannula

Designed to be deltoid-sparing, the Arthrex Anatomic Proximal Humeral Plating System delivers versatile fixation with 7 plate lengths (92-265 mm) to address a wide range of fracture patterns. Featuring variable-angle locking screw options, KreuLock® technology, and integrated FiberTape® cerclage button capability, this system is designed for strength, flexibility, and efficiency.

Arthroplasty Shoulder

Arthrex Anatomic Proximal Humeral Plating System

Speaker  The Arthrex Anatomic Proximal Humeral Plating system is designed to be a limited contact deltoid sparing plate, aiming to avoid taking down the deltoid insertion on the humeral shaft during implantation. This plate features variable angle locking and compression screw technology to provide a streamlined, reproducible reconstruction of proximal humerus fractures. The proximal humeral plating system includes 14 site specific anatomic proximal humeral plates. Seven plates for left shoulders and seven plates for right shoulders. Plates are three whole to 15 whole, with length starting at 92mm and ending at 265mm. Anatomic plates feature a divergent screw pattern with a choice of 4.0mm cancellous or 3.5mm reinforced variable angle locking or KreuLock screws in the head, and a five millimetres compression slot in the shaft, 3.5mm cortical screws are accepted in the first five screw holes of any anatomic plate. Further, distal OR plates that are seven hole or longer screw holes, except 4.5mm cortical screws or 4.5mm FiberTape cerclage buttons. The Arthrex Anatomical Proximal humeral plate is specifically designed to be deltoid sparing, curving anteriorly before the general region of the deltoid insertion on the humerus. Suture eyelets in the bend are intended to assist with soft tissue repair. The proximal humeral plating system requires two instrument trays for clinical use. The designated proximal humeral tray, as well as a general instrument tray. Begin the procedure by using the T 15 screwdriver to secure the alignment guide to the plate. Confirm the plate position by placing a two millimetres k-wire through the hole on the superior aspect of the alignment guide. Speaker  Using the 2.5mm drill guide and 2.5mm drill bit. Drill through both cortices of the oblong hole in the shaft of the plate. Use the depth gauge to determine appropriate screw length and insert a 3.5mm cortical screw. Next, confirm appropriate plate positioning by placing a 1.6mm k-wire through the drill guide. Confirm the k-wire position using fluoroscopy. If using the 3.5mm reinforced variable angle locking OR KreuLock screws, insert the 2.8mm locking drill guide or use the freehand drill guide if using a 4.0mm cancellous screw. Use the 2.5mm instrumentation. Ensure that the drill does not perforate the far cortex. Kreulock provides interfragmentary compression through a variable thread pitch of the screw. The lateral plate will allow for screws to be placed up to 12 degrees radially. From the central axis of the locking hole. Insert the desired screw using the T 15 driver. Repeat the previous steps for the remaining proximal locking screws and confirm appropriate fixation and reduction using fluoroscopy. If additional compression or plate reduction is needed, distally insert the reduction bolt by cortically through a locking drill guide. Thread the compression onto the reduction bolt until the nut contacts the drill guide. Continue turning the nut clockwise until the desired reduction is achieved. If desired, FiberTape. Cerclage. Sutures may be applied prior to placement of the plate or directly into the plate construct using the 3.4 or 4.5 millimetres cerclage buttons inserted into a plate shaft. Screw hole. Additionally, soft tissue may be repaired to the plate using any of the peripheral suture islands.

Arthrex Anatomic Proximal Humeral Plating System

This video reviews the biomechanics and function of the spine and surrounding structures as they relate to pars fractures (spondylolysis). It also reviews epidemiology, incidence, risk factors, pathophysiology and mechanisms of injury, signs and symptoms, diagnostic techniques, and classification systems of pars fractures.

Spine

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Biomechanics of the Spine With Pars Fractures (Spondylolysis)

OrthoPedia: Biomechanics of the Spine With Pars Fractures (Spondylolysis)

Ryan B. Rigby, DPM (Logan, UT), demonstrates using the NanoNeedle Scope and instrumentation portfolio for ankle arthroscopy.

Imaging and Resection

NanoNeedle Scope for Ankle Arthroscopy

All right. Well we're going to insert and show you a little bit on the inside of the joint. Before we do, let me highlight just some portal placements. For my placements I always use a distractor for most of these cases. But on that note, if it's a trauma case, you're not wanting to do all of that. Again, the ease of just putting this in with a needle and not having to do all the setup of a distractor is is again, one benefit to using the nano needle. If I'm doing, say it's an ankle stabilization, I want to scope. We'll use that as a situation today. I do always outline the medial malleolus, the inferior border here. This is the tibialis anterior tendon. You can feel the edge kind of that medial edge. And about a finger width up I make a medial anteromedial portal angling back into the joint. Here it's a nice safe spot, angling towards the fibula. As I insert instruments to establish that first portal, I always start on the anterior medial. I've outlined the superficial peroneal nerve here. We want to avoid that throughout the entirety of our of our procedure anterolateral portal as well. Just being able to instrument and do some work. If you need to reach further for other spurs, you can come even further lateral as well. So there's portal placement. We'll move forward. We're using the high flow sheath. We'll remove this and insert our nano needle. It does kind of click into position. We'll turn on our fluid and we'll look around a little bit and show you guys a couple things here. We'll switch over to the inside of the joint here. Okay. So basically you can see just first off we're inside the ankle joint. But how quickly I can get to the back. Whereas normally that's harder to do. The smaller 2.7 scopes bottom out. And the larger forces sometimes can't fit in here. But I'm easily all the way to the very back of the tibiotalar joint. So you can see the difference in having such a smaller instrument. And also you get a feel of that wide view and just straight on and not looking around the corners with this. So okay, so we're looking at the tibia above, the talus below. We're inserting in our our nano shaver. And we do have a little bit of some synovitis I scope every ankle stabilization because they typically nearly 100% of the time will have synovitis. So we'll work some of this out and you can see the picture quality. I mean, this is cool technology, especially being such a tiny little scope to have that kind of quality here and the ease of just using this on the iPad, if I want to, I can turn the the microphone on and tell the patient, this is all the scar tissue and inflammation that you've developed over years of spraining your ankle and just work around. And you can see, even though this this little saber shaver is a small shaver, it's still very aggressive and and works nicely. And I'll, we'll use it to show some diagnostic purposes or value of it as well here. So I just wanted to show you I left all the all the synovitis when we first entered the joint, so that I could show you just how quickly and easily that works. I do love how smooth it is in entering the joint without these teeth that will will scar the cartilage so smaller, smoother, but still aggressive and great suction. You know, one thing while we're here is just coming back. You can see how we can work towards the back of the joint, clearing out any synovitis or herniation of the syndesmosis. One thing I think we all should be documenting, based on the papers that we have now, is the syndesmosis, especially in the setting of ankle instability. And so based on several papers, one being Guyton's paper, which talks about the ability to insert a three millimeter probe into the syndesmosis would be indicative that you now have global instability laterally, medially with the deltoid and the syndesmosis. And so I always just come up and say, okay, can I insert instruments into the syndesmosis on this patient? It's negative. And I would document that in the OP report and say the syndesmosis appeared intact, I could not insert my shaver into the syndesmosis. Arthrex also has probes that come at various sizes that you can use to put in there as well, and you'll be surprised if you do that every once in a while. You'll run into one where I did not realize, hey, they have some syndesmotic instability and you can slip that shaver up in between the tibia and fibula, and you should be placing TightRope or an anterior TfL internal brace. I'll also come to the front of the fibula here and just push on it from front to back, and you can see that Syndesmosis is nice and tight there. If that was unstable, you'd be able to see a little anterior to posterior translation, but also just highlighting again the saber shaver, how I can get up into these little tight areas and just kind of clean some of this stuff out here. So there you go. That's that's the arthroscopy portion of, of this demonstration. Let me switch the portals and we'll talk just a minute, a little bit further about something I'm excited about when it comes to ankle stabilization and making decisions on which ligaments need to be, which need to be repaired. Just. And you and I have had several conversations and conversations and working on projects together. So I've switched the portals. I usually for me, I do like to have the the flat part basically facing up towards the tibia or the patient's head, and that gets me oriented on the camera. So I know that I'm looking up at the tibia. It just helps me keep orientation within the joint. Switching portals here. Come around to the medial side, get our shaver in. Still a little bit of some synovitis that we can work on. Let me clean that up a little bit further and then, you know, let's talk a bit about the deltoid. I've got some data that I'm about to it's actually been submitted for publication, finding the incidence of the deltoid being involved in ankle instability. And we're finding it's 20 to 30%, which is a lot higher than I previously was repairing. So we're working on techniques to diagnose basically identify when that actually needs to be repaired. And in the trauma world, they've called it a drive through sign. And in the acute setting, that's, I think, still very applicable and appropriate. And what that looks like is if you come over here to the medial gutter and you take a shaver, I usually, you know, in an ankle scope, we'll use even up to a four millimeter shaver. But you can come over and you can peek around the corner and you can look down at the deltoid and see if it's torn, or do this drive through sign in in the medial gutter. And if your shaver fits in between, if you can, take and insert it here, just as we've done down in between there. And it fits quite easily. And so just to give you a heads up, I did release a good portion of the deltoid just in preparation so I could show you this maneuver. But this and this is a smaller shaver, but as you can see, that fits. So if I have a four millimeter shaver and that fits in there, we know that that deltoid is a little bit incompetent. There's a little bit of some subtle instability. Maybe it's not gross instability with severe valgus tilting, but there's a little more global instability from medially to laterally. So that's the drive through sign. You'll see papers starting to come out. We have data we're publishing on this. We actually validated this in the lab in the last couple of months. But this is the medial drive through sign. And even you can sometimes just take the shaver and even just push and see the medial side open up at times. So I wanted to highlight that as well. Some of the diagnostic things. If you're not scoping your ankle stabilizations, you're missing out on a lot of pathology, and there's nothing worse than having a nice stable ankle that still hurts from all the synovitis still in there. Document the syndesmosis that it's intact and stable. You can document, of course, osteochondral defects, frequent things we encounter in ankle instability. And then the deltoid. Was the drive through sign negative or was it positive? And if it is I encourage you to go. We use a couple of FiberTaks typically here. The new knotless FiberTaks work well to do a medial deltoid repair.

NanoNeedle Scope for Ankle Arthroscopy

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

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

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

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

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

Grant Garcia, MD (Seattle, WA), demonstrates the use of the divider cannula and Knotless 2.6 FiberTak® soft anchors from the Remplissage Implant System. The video highlights anchor placement and interconnection through the divider cannula to create a tensionable knotless remplissage construct. Dr. Garcia also shares surgical pearls for suture management, and staged tensioning to reduce the infraspinatus into the Hill-Sach's defect for a secure and efficient instability repair.

Shoulder

Tensionable Knotless Remplissage Technique Using the Knotless FiberTak® Remplissage Implant System

Speaker  Grant Garcia here from Seattle, Washington. Today, we're going to demonstrate the Remplissage kit, and we have the 2.6 FiberTaks that we're going to use for the repair. The majority of the kit you're going to see in the video demonstration, you have a new handle system, then the divider cannula and then the removable divider. Okay. So you can see here we have a left shoulder. This is the lateral positioner we're in. You can see that here we have a labral tear which we're going to fix shortly. So anterior labral tear posterior labrum actually is in a pretty good position. We're using the PanoScope so you can see the views a bit better as well. So now we're going to do our Remplissage anchor. We use these two needles to mark out our trajectory for our anchors to make sure that we have the appropriate infraspinatus bite for the Remplissage. And then in the middle, we're going to split down here and use the divider cannula to place both the anchors safely through the cannula and allow us to interlock that infraspinatus down. So this is the new divider cannula system. This is really nice. It's got a sharper tip trocar. But this will not penetrate through the capsule. And you're going to enter this in and sweep. So the trick here is to sweep. You can see the tissue being molded. Speaker  You will not engage any of the Bursa. You will not engage the deltoid if you do this. So it's really important here to highlight the orientation of this because the cannula is not a perfect circle. It's an oval. So now we've turned it locked it into the skin here. And you can see the way it's being held. This is excellent. Up and down is going to be the where the cannula is placed on the inferior superior aspect. Again we're in lateral position. This is where we're going to lock in our sutures. This allows for suture management. So it's a really nice cannula system specifically designed to make sure that Remplissage is easier for the user. So here we can actually place this removable divider in. And you can see the way that it's angled the divider. So you can easily place your anchors through it. So the nice thing about this handle is ergonomic. It's got a place for your thumb. So you can help you get through the infraspinatus. So it just goes right down there. It almost actually gives you the position that you want to go. And then we're going to just gently push this in. This is quite sharp as you see. So we've got good space there. It goes in very, very easily. So you have an option obviously of doing this percutaneously. Speaker  But I don't find that necessary in this scenario. What we're going to do is going to go right on the margin of that Hill-Sachs. And then we can just place the anchor and you already have the first one set. Okay. So now we're going to place the first 2.6 Knotless FiberTak. You can see there's a laser marker, so you don't have to go all the way down. So you can mount that in. Excellent. And you can see we have a really nice view here before I take out any of my Cam systems actually engage the anchors. And we're talking on this pretty hard. So it's nice. It's set really well. So we've removed the handled guide system. So one trick here is not to actually push too hard on the suture because of this unique cleating system. If you push too hard you actually will perform a Remplissage with the cannula in. So you want to just relax here, put this amount of tension and then you can actually nicely lock this in, which is really unique system. So now you've locked that in. So now we can place our second one. Okay. So we placed our first anchor again. The key here is inferior anchor first, then superior anchor. You can see we have a really nice view superiorly. Speaker  So we're able to place this without any issues. So watch as I place this through the cannula. You obviously don't want to go through the same hole that you just did. But because of the uniqueness of this divider, you can go through the superior hole and you have no concerns about damaging your sutures. Okay, so now we've placed the dilator and guide in for the superior anchor. You can see we've got good spacing. You'll make sure you have adequate enough space in at least one to 1.5cm, and you want to span the entire Hill-Sachs at least one to 1.5cm. The nice thing is the footprint on these anchors is quite small, so you have a little bit more leeway here, and you can see where the fish mouth again and again. What I'll do is I'll just push this fish mouth in a little bit better. So you can actually use it as traction and see better. And then you put your fish mouth. And we're just going to make be aware of our other anchor, which were plenty of space. Okay. And then we're going to place it, make sure we have a comfortable hold. And now before we remove this handled guide system, I'm going to load the anchor. As you can see they're loaded nicely. We can remove the guide system. Speaker  And now the space opens up again. And then again. Similarly you're going to cleat this. Great. So now we have our anchors placed for the Remplissage. We have enough space between the two. What I will do is I'll actually interlock the anchors for the Remplissage. The key here is to not fully tighten it, because you can make the posterior aspect more tight and or the entire shoulder more tight and more difficult to fix the anterior labrum. So you'll see the uniqueness of this cannula system. So now we can remove the divider. Okay, so I'm going to take the repair stitch from the superior anchor, and I'm going to lock it. And you can see that assistant is an excellent job of already locking the whole system from the inferior anchor. So they don't get pulled together. So we have our loop here, similar to having any of these knotless options. And then we're going to pull the repair suture through it. And you're going to go to the laser mark. Now we have our pull stitch. So we're going to slide this and guide it all the way down. And you're going to wait till you just see the capsule pucker just the tiniest bit. So right there we're starting to see it pucker. So we're going to stop. Speaker  And then this we're going to cleat out of the way. And now we have the repair stitch from that anchor, the superior anchor. And we're going to do the interlocking mechanism from the inferior anchor. To allow us to do our double knotless Remplissage. So now we've cleated these stitches. We have not final tightened. As you can see here, it's essentially puckering. This actually is helping that humeral head pull back. And what we're going to do now is go and finish our bankart repair. And then we're going to come back and final tighten. Okay. So we did most of our Remplissage. Then we went and completed our bankart repair. You can see here and retension it. So we have a nice labral repair there. So you can now release the lateral traction. And we're going to go back and we're going to finish up our Remplissage. So we're going to just pull some of the tension out. You can see it's sliding really nicely. And then we're going to repeat that. And you can see even if we pull this away, we've taken all the traction off. This is not going anywhere. So we've final tensioned here. And you can see how this nicely centered it. Now you can actually see this a bit better. It really pulled it back nicely. Now we have our Remplissage completed.

Tensionable Knotless Remplissage Technique Using the Knotless FiberTak® Remplissage Implant System

The Rotator Cuff Express Instrument System was designed with ambulatory surgery centers (ASCs) in mind, featuring a single-level, low-profile, and customizable layout that houses the latest instrumentation for Arthrex’s next-generation implants. Ideal for smaller surgery centers with cost and space concerns, the case also complements larger “master sets” at busy hospitals and is configurable to suit your needs and preferences.

Arthrex Rotator Cuff Express Instrument System

Arthrex Rotator Cuff Express Instrument System

This video discusses the decision-making process and surgical management options for the treatment of tibial plateau fractures.

Trauma Lower Extremities

Tibial Plateau Fractures: General Surgical Considerations

OrthoPedia: Tibial Plateau Fractures: General Surgical Considerations

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

Osteochondral Lesion Treatment With the 20 mm Precut OATS® Kit

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

Osteochondral Lesion Treatment With the 20 mm Precut OATS® Kit

Saqib Hasan, MD (San Francisco, CA), demonstrates a percutaneous approach to pars fracture fixation using the fully threaded spine compression screw with optional endoscopic debridement of the fracture.

Percutaneous Pars Fracture Fixation

Speaker  Hello everyone. My name is Doctor Saqib Hassan. I'm from Golden State Orthopedics and Spine. And today we're going to be discussing how to perform a percutaneous pars fracture fixation with or without debridement of the pars fracture depending on the chronicity of the pars fracture. So the first thing we want to start off by doing is make sure if we're going to be using fluoroscopy and not navigation, is to make sure we have excellent fluoroscopic imaging of the pars on both the AP and lateral plane. Again, without navigation, this procedure can be very challenging. If you are not sure where the starting point is for your incision. Another important part of positioning the patient for this procedure is to ensure that the patient has the proper amount of kyphosis of the lumbar spine, because we all know that patients who have higher incidence of pars fracture have been known to have a higher pelvic incidence and have more lumbar lordosis, which can make this procedure more challenging if you're trying to fire a screw with significant lordosis. So again, what we did in this particular specimen is that we've added a lot of bumps to increase the kyphosis. And if you were to do this on a patient, I would recommend using a Wilson frame instead of a Jackson frame to avoid the lordosis. So let's start by actually marking. That's going to be the position of our screw. Okay. All right. We're going to mark that. Okay. So as you can see on my AP radiograph, what I did is I marked a starting point from the bottom of the lamina going across the pars bisecting the pedicle. Speaker  I'm going to actually make it right in the middle of the pedicle. Maybe angle a little bit medial. So you can see that in this particular X-ray I'm bisecting the pedicle. I'm not too lateral to the pedicle. So my screw is going to have nice fixation in the pars. And I have a good starting point on the lamina with the inferior articular process. So we're going to take that incision. We're going to bring it all the way down. Okay. And then I'm going to do a similar one for the opposite side. And then we're going to do that right there. Again. That's pretty good. We're on the inferior articular process lamina junction. And I'm bisecting the pedicle. I'm going to mark that one. I do the lateral line because I know that my trajectory is going to be kind of like this. So I'm going to use this angle and then I'm going to actually meet in the middle right there. I'm going to try this one first. So I'm going to go mark the angle hit spinous process there. Okay. I have the right trajectory on the AP. I have to make sure my lateral is good to make sure I land on the pars. Okay, so that's pretty good. That's right in line with our pars. So now I'm going to have a good approximation of where I'm going to be. Speaker  I can still make some micro adjustments. So it's important to understand that it's okay if you're not perfect on the first go. All right. So we're going to swap that out. We kind of know where we're going to end up being. We know that we're a little bit lateral. So I'm going to watch that again. I'm going to angle there. I like my position on the lateral. I'm going to go more steeper. All right. I like to typically now that I have my position I'm going to mount this a little bit. Okay. Let's get that in there a little bit more. Okay, I like that. So what I'm going to do is I'm going to drop my hand. You see my, my trajectory, obviously it looks good. It's just micro adjustments. We're going to we're going to pull this back a little bit. So you can see that I have a good pars trajectory. You can see that I'm bisecting the pedicle and the key is on the AP. You want to stay lateral to the medial particular line. Because obviously if you're medial to the medial particular line you can have injury to the traversing nerve root. I think I'm going to have good fixation there. Now what we're going to do next is we're going to take our wire out and measure. Now this part can be tricky. Obviously, if you're on navigation, you can do an intraoperative measurement of the navigation. Next we're going to do is we're going to insert our dilator. Speaker  Sometimes you can experience a little resistance. Now we want to measure the length of our wire. And you can see I have this drill guide, which is very helpful. The point of this, of this drill guide is to be able to catch the lamina. Okay, you can see that this drill guide has two tines. And the point of these tines are to be able to have some grip of the lamina. So the tendency can be when you're doing this drilling is to skive this way or that way, but the tines actually help you quite a bit in making sure you you have the appropriate trajectory and you don't lose that trajectory when you're drilling the path of the guide wire. So we're going to do that again. We're going to take our tines. We're going to put this in here like this. Again, you have to kind of rotate to get through because of soft tissues. Now I'm in my position. I'm going to always drill on the lateral okay. Because I don't want to skive. The tendency is to skive superficial or deep. And we're measuring on our guide. Our measurement is showing that we are approximately 35. So I'm going to on the side of 36 because I think we have our wire just a little bit shorter. And a nice little trick to do is to make sure that the tines of this soft tissue drill guide are on the lamina. You can do a gentle tap. Speaker  And then again, we can just double check our length. We can see I like that position. I think 36 is going to be perfect. Okay. And now we can commence with our drilling. Now one little trick that you have to remember is that obviously we know that everything we're doing is based off this guide wire. You can see the guide wire is not sitting in the middle of the hole. So I like to kind of just make sure we adjust this so it sits right in the middle. You see now it's perfect. And if you pay attention to the last AP, the drill guide was a little bit off, but this is how you can make sure you're staying in the center. Because if it's in the center, you know that you're drilling right in line collinear with this wire versus off axis if it's like this. So a small tidbit, but it helps a lot to make sure you maintain your position. Okay, I like my position there and you can always do some minor corrections if you need to. Although I don't recommend too much correction because then the guide wire might catch. So I like my position there. I'm going to start right now we're at 36, but I think we're closer to 40. So I'm going to take a 40 on this one. Yep. I like that a 40. I'm going to take that at 40. Typically when you are measuring the width of the pars screw, I like to use a preoperative CT to see about how wide that pars is. Speaker  The average is about anywhere from 4 to 5mm. In some patients you might have six, but I think generally 4 to 5 is the average. So we're going to be taking a four by 40 millimeter screw. Okay. Now here's our screw. Nice. I'm having a nice bite. I already feel the bite here in the compression that's happening. I'm kind of at the end point. I feel a lot of resistance. You don't want to go too far. Okay. And then now that we're done. Pull that out. So you can see now that we're done putting our placing our screw, we can pull our guide wire. That looks very nice. I like that I didn't have it too deep or I can still retrieve if needed. It's right down the middle of the path and that looks beautiful. You can see we bisected the pedicle. I like my position. It's right where the pars fracture would be. One other thing we want to touch upon before we conclude is what you would do if you had a chronic pars fracture, the steps would be a little bit different. We walk through the instrumentation part, but what I would typically start with is I would actually start by localizing on the pars with my endoscope. So again we showed the direction of our pars screw. So what we would do is prior to actually beginning the instrumentation portion, I would localize to the pars fracture right here. Speaker  And it's important that you debride the edges of a of the chronic pars fracture. Because typically you're going to find a lot of scar tissue within the fracture site, which can impede bony healing. Typically when you have fracture gapping and it's a chronic pars fracture, it behooves the surgeon to perform a debridement. And typically if you want to perform this the most minimally invasive way, I would obviously do this. Endoscopically we have patients who are high level athletes who are trying to return to sports. It makes the most sense if you're going to do minimally invasive pars fixation, also do a minimally invasive endoscopic pars debridement right here. So we already put the screw in. So what we're gonna do is we're going to debride that area. And hopefully we're going to be able to see the position of our screw in a nice position. So what I'm first going to do is draw a line that is just parallel to the pars fracture. So I know that my pars fracture is somewhere around here. And because we're just going to go direct onto the pars fracture there's not much more that needs to be done except just mark how lateral you're going to be. That's typically where you'd find the pars fracture. I'm going to make a mark right there. And then I'm going to take my incision. Okay. Get this needle in here. And I'm going to take this here. And I'm going to just do a little soft tissue dissection again. Speaker  And let's just make sure we like our position on the pars. That's it right there. Okay. We're going to hold that position. Okay. And we're going to go right there. Yep. You can see on the X-ray I'm right where the pars fracture should be. Okay. So if the AP in the lateral all line up, then all means they'll have us go a little bit deeper. I'll see that PA screw. Okay. And you can actually see this is medial okay. As I walk down here it's lateral and you can I'm falling off the edge here. So my part is right here. This is the pars. Obviously there is no pars fracture in this in this specimen. And we're going to create one. But the idea is that when I land here you would see a lot of soft tissue. You would feel bone here bone here and you'd feel soft tissue in between because typically there's some fracture gapping there. So you can see our part fracture would be here. We can start to see some of the screw that I don't want to drill out the screw, but you can see the screws coming this way. In that trajectory, you can actually follow the screw. It's actually coming this way towards the top of the pars. And this is our trajectory. You can see all the threads of the screw there. Essentially when you're doing this, the workflow is for chronic pars fracture. Once we have debrided the pars fracture, we would then have the scope holder kind of look at the fracture site. Speaker  And then what we would do then is all the steps we performed before, whether doing it with fluoroscopy or navigation, you would then fire the guide wire first, and then you can drill over that. And you can actually directly visualize your drilling as well as your guide wire placement. So it adds that extra level of security knowing that you're in the right spot. You know, we're very close to neural elements here. You want to be very, very exact and precise when you're doing this procedure. So I always will start with my debridment and make sure I know where my pars is prior to putting the screw in, I do put some biologic bone graft into this defect. It helps that there's bone graft into the defect prior to adding the compression screw, and it will help to compress some biologics within that pars fracture zone. Another important element is to make sure that when you're debriding, to make sure you have bleeding bone at the site of the pars fracture, that also encourages bony healing. As far as post-operative protocol for the patient, we typically will place the patient in a LSO brace and limit lumbar extension. For the first six weeks. We will start gentle physical therapy at six weeks with avoiding hyperextension or extension exercises. And typically the return to play can be anywhere from six months to a year for most active athletes.

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OrthoPedia: Biomechanics of the Spine With Pars Fractures (Spondylolysis)