Michael Swartzon, MD (Miami, FL), compares the compositions of platelet-rich plasma and bone marrow concentrate; reviews their efficacy, durability, and safety; and provides rationale for using both types of biologic treatments when treating knee osteoarthritis.

Orthobiologics

Human

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Bone Marrow Concentrate vs Platelet-Rich Plasma

OrthoPedia: Bone Marrow Concentrate vs Platelet-Rich Plasma

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

Shoulder

Not Hidden

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

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

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

Edward Haupt, MD (Jacksonville, FL), presents a case using the NanoNeedle™ scope 2.0 and release kit in an endoscopic gastrocnemius recession procedure.

Imaging and Resection

NanoNeedle™ Scope 2.0 for Gastrocnemius Recession

Speaker  Hello, I'm Eddie Howe from Jacksonville, Florida, and today we're going to talk about NanoNeedle scope for Gastroc recession. The current system that you're used to uses a scope tower as well as normal arthroscopy trays. Obviously this is cumbersome for the team, and there are improvements that can be made upon this to make it easier for you and for your surgery team. The NanoNeedle scope is a 1.9mm scope with a single use kit has everything you need, both for the arthroscopy or endoscopy portion and also the instruments you need to complete. The Gastroc recession is in the kit, and the kit used for the Gastroc recession specifically comes with every instrument you're going to need for the case. So there's a translucent cannula with an obturator to find the right place. There's a plane finder, which works as a switching stick. If you can't get in the right spot, multiple different blades and arrested for visualization as well as several Q-tips in case you need those. So why NanoNeedle endoscopic gastroc recession? For me, I get this much range of motion that you're seeing on the screen with very little incision and no extra trays of process, which is huge for my team. So obviously I'm showing you an image. They're gaining about 15 degrees of dorsiflexion with just a couple poke holes. So how do I set up the room? This is my exact setup pictured here where I'm looking off to the left to a NanoNeedle console. Speaker  It's a typical supine setup for me. You can use a mini or a large C-arm, a thigh or calf tourniquet. If you use a calf tourniquet, just be smart that you place it high enough that you're not going to be in the way of your instruments here. I'm doing this with an ankle replacement, so you can do it with as complicated of a case as you want. You're going to want to have a towel bump ready for a more working room as you're working with the leg, and you're going to hold the foot with your chest for a portion of the procedure. So how do you start this? You're going to make a 3 or 4 millimeter incision just a little bit bigger than a knife blade at that junction of the gastrocnemius and its aponeurosis, you on the side of being a slightly distal incision, as I have pictured here. Notice that the leg is on the towel bump. To give me some more room, I'm going to make the incision and then blunt dissect down to the crural fascia of the leg. I usually use a hemostat for this, and once I get to the fascia, you're going to perforate that. I typically use the pointed obturator to do that, but you could also do it with the snap. I think it's easier to do it in one step with the pointed obturator. Speaker  Do this with the ankle in plantar flexion so that the calf muscle is loose. It'll be easier to find your plane with the ankle plantar flexed. You're gonna place your cannula into position where you're in between the crural fascia of the leg and the gastrocnemius aponeurosis. You can check with the scope before you perforate laterally. You're going to eventually need to make a lateral incision, but you can look before you make that incision and make sure you're in the perfect spot. So here's an example of a first pass. You'll notice that when the video plays that you can't see at the other side. Because I haven't made that incision yet. When I'm looking in and I'm going to be in between the fascia of the leg posteriorly or on the bottom of the screen and the gastroc aponeurosis on the very top of the screen, which is that white band. It's a little too much fat on that image, obscuring my view of the aponeurosis. So I'm going to use the rast included in the kit to mobilize that soft tissue off of there. We're going to pass a few Q-tips and check again. So here's me placing those Q-tips through the cannula that's already in there, showing how easy this is. And you can obviously see the NanoNeedle scope on the bed as well as the blunt obturator. The view you want is going to be with the cannula. Speaker  Obviously in place, shows the gastroc aponeurosis at the top of the screen and the crural fascia right behind it, and it's a perfectly white gastroc aponeurosis. So that's an image there on the left. And also what it looks like with the hook. So you can see even better than you can open with the scope. Don't proceed until you have a great view. So once you have that perfect view, puts the operator back in, perforate the crural fascia laterally, tent the skin over the obturator and make a stab incision with a knife and pass that out the other side. You'll need to instrument through the cannula with the scope and the hook blade. A great question is how do you cut with a hook blade? So you're going to tension the fascia with the ankle dorsiflexed that tension is going to help the blade cut and use the sharpness and the curvature of the blade. Hook it onto the aponeurosis, gently pull it and cutting as you go, but make small twists with your wrist to keep it from getting snagged. And here's a few videos of exactly that. So the hook blade is going to be placed right against the aponeurosis. And then you can see it. Sometimes it cuts very quickly and easily. But other times, if it seems like you stop making progression with the blade, just make little twists like I'm showing right there to continue to advance under control, you want to avoid the blade plunging out of the leg, and you do that by making just gentle little twists. Speaker  When you get snagged, you can see it's easy to even go back and release a little band there that maybe not captured on the first pass without having to pull all the way out. Here's another video of the same thing. Gentle traction with the hook. Gentle twist leads to a very precise cut going all along the length of the gastroc aponeurosis. It's very subtle. It's very similar to the way you use a Cobb elevator, where you use gentle twisting of your wrist to elevate the tissue. So here's kind of that, the full view. I have the camera in one side of the cannula, or passing the hook all the way in and hooking it against the gastroc aponeurosis with a nicely tensioned with ankle dorsiflexion. And you're going to notice I'm going to start to pull a little traction doing gentle twists through the hook as we go. Very subtle twists and I'm releasing the Gastroc aponeurosis as we go. You can notice the soleus fascia is behind the Gastroc aponeurosis there. So this is a perfect release as we're moving along here that the soleus fascia is left intact. And that was it. So it's a very quick, straightforward case. Once you find your plane obviously with very small incisions. Speaker  And this is exactly why I do it. There's preoperative image on the left there. Maybe we can dorsiflex that to neutral right after the post-procedural, I can get another 10 or 15 degrees exactly what you'd get with an open gastroc recession. The tiny incisions than I would argue it's a faster procedure. So thank you for watching this. I think the indications for this procedure are contraindications are the same as any gastroc recession. The pearls here is the gentle twisting of the hook allows for easy blade passage. This procedure, once you get used to it, really shines and individuals. You'd have to make a large incision for your Gastroc recession. So obese people, overweight patients, individuals with a larger leg. I think the pitfalls to be aware of is the exposure, like any surgery, is key. Don't pass the hook blade unless you can see well and make sure you can see well before proceeding. My recommendations for somebody starting out with this is perfect. The location of that portal incision. That'll be easier with skinnier patients in the beginning. You can expand your technique as you get better. And you also want to perfect the location of your cannula underneath the fascia as well. I think the key there is paying attention to the position of the ankle. Keep the muscles loose. When you perforate the fascia, tighten them up as you're passing the blade and putting your cannula in position.

NanoNeedle™ Scope 2.0 for Gastrocnemius Recession

Paul Saluan, MD (Cleveland, OH), demonstrates an all-epiphyseal ACL reconstruction (ACLR) using the all-inside QuadLink™ technique with pediatric small-angle marking hooks and the FlipCutter® III drill to safely avoid the physis. Dr. Saluan also uses the new FiberTag® TightRope® II implant, featuring the TightRope II button, a flat-tape TightRope loop, a shorter minimum loop length, and an improved atraumatic needle.

Knee

All-Inside, All-Epiphyseal QuadLink™ ACLR: FiberTag® TightRope® II Implant and Pediatric Guides

All-Inside, All-Epiphyseal QuadLink™ ACLR: FiberTag® TightRope® II Implant and Pediatric Guides

Marc Szadkowski, MD (Lyon, France), presents a case of a 51-year-old male with a paracentral disc herniation at L3-L4, treated using an endoscopic trans-SAP decompression approach.

Spine

Endoscopic Trans-SAP Approach for a Paracentral Disc Herniation at L3-L4

Speaker  Hi, I'm Mark Szatkowski. I'm an orthopedic surgeon from the Santee Group from Lyon in France. And today I will show you a trans Sapi approach on l3-l4 level for a paracentral disc herniation. So the trans Sapi approach gives the surgeon the opportunity to increase the power of foraminal techniques to reach difficult anatomical sites by removing extra articular bone from the sap. This approach has many advantages. First, you duck on a highly secure zone far from the exiting nerve. You increase the size of the foramen to explore the canal, and you have a better view on the shoulder of the transversing nerve root. This is the case of a 51 year old gentleman, a heavy worker, and for one month he had a bilateral posterior leg pain. And he came in the emergency to the office because for two days he had weakness in the right leg. On the clinical examination, I had a positive straight leg test, 30 degrees bilateral. And the patient had a motor deficit on the dorsal flexion and on the quadriceps. Here is the MRI. And on the axial view you can see that the dura is severely compressed by your paracentral disc herniation on the level l3 l4. Here you can see in red the disc herniation that is located slightly more on the right side. In green you can see the dural sac that is severely compressed on the sagittal view. Speaker  You can see the level l3 L4 with a disc herniation that goes cranially and caudally. And here you have the same view with the disc in red at the L3 L4 level. The interlaminar window that you see in red is lower than the disc level. So if you want to decompress the dural sac in an open fashion, you have to remove a lot of bony structures, including the ligaments. So the main advantage of the trans sap approach is to leave all the posterior structures intact, and to remove a small extra articular piece of bone to go inside the canal to have a better view on the disc herniation and the dural sac. The planning is to remove a piece of bone that you can see in blue with the dedicated reamers. After docking on the sap here, you see the AP view. First you have to draw a vertical line, which is the midline and a horizontal line, which is the level of the injury. Then you draw the direction you will have to use for this technique, and you will start always with the lateral X-ray. And the aim is to dock more shallow than in a transforaminal approach. On the sap here you can see a lateral view of where you have to dock. Then by using Corona Reamers, you start to create a bony channel in the sap. Speaker  Here you can see the bony channel. You progressively increase the size of the channel in order to put the working channel inside. On the left video, you can see the bony removal and the remaining ligamentum flavum hiding the dura. You can remove this thin layer if you need it with a Kerrison punch. You can also drill the tip of the sap if you want to go more Cranially. On the right video, you start to see the dura that is proceeding. Now as we started to remove the disc herniation, now the dura and the nerve are free. You can see the transversing nerve root and the PLL you can easily reach with this approach to cranial part of the disc. As you can see on the X-ray done with the probe inside for the postoperative period, we ask the patient for four weeks to work and to avoid active physiotherapy at one month post-op. After examination by the surgeon, the patient can return to daily life activities while starting active core training. So this is a great option for patients because you can address multiple conditions like migrated disc herniations, foraminal stenosis, and even recess stenosis combined with disc herniation and without removing any ligament or facet, which ultimately gives the quickest recovery. Thank you.

Endoscopic Trans-SAP Approach for a Paracentral Disc Herniation at L3-L4

Erik Kubiak, MD (Las Vegas, NV), demonstrates using the QuickPass™ FiberTape® cerclage system to achieve reduction of an oblique fracture of the distal femur. He provides an overview of the unique instrumentation that allows for a faster, more efficient technique to pass FiberTape cerclage around bone. The FiberTape cerclage with QuickPass tube is used in conjunction with the cannulated, slotted QuickPass passers to place the FiberTape cerclage around the fracture twice without the need for a separate shuttle suture.

Long-Bone Fracture Management Using the QuickPass™ FiberTape® Cerclage System

Speaker  Eric Kubiak from Las Vegas, Nevada, demonstrating the Fibertape cerclage with quick pass tube. Before you. We have the Fibertape cerclage with quick pass tube. The three straight passes medium large and the exaggerated curve passer. The advantage of the Fibertape cerclage with the quick pass tube is that it really facilitates the two passes of the Fibertape Cerclage, much like with the similar ease to the single pass of a of a steel cable. Without all the disadvantages of the steel cable you can see demonstrated here the channel in the passer. And now we'll take the quick pass tube. And slide it through the channel. Retrieve. You can see the tape clears and then you can pass second loop. And now you have the two passes without having to use the Fiberlink. Extensile direct lateral approach to the distal femur in the setting of a modeled long oblique fracture of the distal femur. This is a typical place where one might employ cerclage for provisional reduction and stabilization prior to definitive fixation with either plate or retrograde intramedullary nail. We find this often in the setting of periprosthetic injuries, particularly proximate to a distal total knee or distal to a proximal femoral implant. Now we will demonstrate passage of the passer once a cable passer has been deployed. So now with the passer around the femur we'll take the quick pass tube pass it through. It's my preference to use the near side of the pass on the handle side. I think it's a little bit easier than passing. Speaker  Oftentimes, the leading end of the tube has some muscle or little bits of tissue in it, and the near side is cleaner. With that, you've got two wraps around the femur and the tube can be recovered. Take the end, pass it through the nitinol loop. Not too much of a loop. You don't want the doubled stranded component of the Fibertape cerclage to really, at this point, you don't want it engaged because it'll make it a little bit. Recovery of that difficult. That's through close. Begin to close the hitch. You can already see the fracture is beginning to be reduced. With the disposable tensioner. You really want to make sure. Oftentimes it'll you'll have used it before, and some of the excursion of the tensioner will be consumed. Just make sure that you back it off, have reversed it all the way before you go to tension. That gives you the maximum amount of excursion. Make life quite a bit easier. I'll pass a double strand through. Lock on the cleat, tighten to. At a minimum of three. I like somewhere between 3 and 4 bars. Back it off all the way. I'll back it off. Slide it forward. Take one strand. Separate cut. I don't disengage it from the holder. Makes life quite a bit easier. Then pass a half hitch. Slide it. Secure the one side Through the loop. The open end two passes around and then two passes through the cleat. Speaker  Retention to 3 or 4. I like four. We're good. You can back this off. And pass another half hitch. You don't even have to back the sleeve up past the half hitch. Over. Reload it. Leave about a five millimeter cuff. There you go. The nice thing about this compared to cable is you don't have this. This cuff isn't going to lacerate tissue. It's not going to potentially inadvertently injure an artery. You're never going to get an arterial laceration with this soft uhmwpe material on a long spiral like this. I typically use two cerclages for stabilization before placement of a nail or plate. So we're going to demonstrate the second here. We've gone to the larger parser to facilitate getting around the distal flare of the femur. Again using the quick pass tube. One pass. Easy. Second pass get false free of the tube. What we have before us is the Pre-reduction image and the post-reduction image after application of Fibertape Cerclage, you can see the broad displacement. You can see how the Cerclage has done a fairly adequate job of reducing the fracture. We're still probably a millimeter and a half long, but that's going to go away with the final implant, either the nail or the plate. But overall, a quality reduction, at least as good as that I can achieve with a clamp. But unlike a clamp, I can leave it behind and basically maintain the reduction through the whole surgical process.

Long-Bone Fracture Management Using the QuickPass™ FiberTape® Cerclage System

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.

Foot and Ankle

Experience the Syndesmosis TightRope® PRO Difference

Experience the Syndesmosis TightRope® PRO Difference

George T. Matic, MD (Cincinnati, OH), discusses the benefits of micro fragmented adipose tissue (MFAT) and reviews literature comparing its efficacy to other treatment options.

Blood and Molecular Science: Literature Review on Microfragmented Adipose Tissue

OrthoPedia: Blood and Molecular Science: Literature Review on Microfragmented Adipose Tissue

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

Rachel M. Frank, MD (Denver, CO), treats a patient with a full ACL tear using the all-suture TightRope® SB implant and a quadriceps tendon autograft. Dr. Frank also discusses her use of the QuadPro™ tendon harvester and reviews graft preparation steps.

Live Case: TightRope® SB Implant and Quad Autograft for ACL Reconstruction

Speaker  Hey everyone, it's doctor Frank here. We're getting ready for a busy day of surgery. Our first case up is a patient with a complete ACL rupture. You can see here on the MRI complete ACL tear, pivot shift, bone bruise pattern. An amazing candidate to undergo ACL reconstruction. Our game plan is an ACL reconstruction using quad tendon autograft with the TightRope soft button with internal brace. Let's go operate. We begin with the quadriceps tendon Autograft harvest. We do this by making an incision approximately 2 to 3cm in length, starting approximately one fingerbreadth above the superior pole of the patella. After we incise through the skin, we'll get through the subcutaneous tissue and we'll get down to the peritenon of the quadriceps tendon. Then we'll use the QuadPro harvester to mark our starting point on the superior pole of the patella. We'll then use a number 15 blade scalpel to dissect the distal aspect of the quad tendon in a full thickness fashion. Once we've dissected the tendon for about 3 to 4cm, we'll whipstitch the distal aspect of the tendon. Next, we'll use the QuadPro harvester to go ahead and harvest our quadriceps tendon, aiming toward the superior aspect of the tendon in 360 degree fashions will aim for a depth of about 65 to 70mm in most patients. Once we've achieved our desired length 65 to 70mm, we'll use the push rod to amputate the quadriceps tendon proximally. Speaker  You can see a nice full thickness quadriceps tendon harvest. And then we'll go to the back table. And this is where the soft button technology will really shine. You'll use the graft clamp like you would with any other FiberTag TightRope, and you'll prep the TightRope onto the graft the same way that you would prior to the soft button technology going up and down through the FiberTag. But now we're going to really see what the FiberTag TightRope soft button technology is all about. The yellow portion that you see is the button that's replaced the metallic cortical button, and by pulling on the included TigerWire and FiberWire sutures, we can elongate the button so that it'll pass through a cortical hole. We'll do the same thing on the opposite side of the graft. And in this case we're showing the internal brace. So this will be used on the femoral side of our graft fixation. Next we'll compress the graft and the compression tube's on the back table so that we can get as tight of a draft as possible within our tunnels to get a nice solid ACL reconstruction. Maintain the graft on tension on the back table with a vancomycin soaked saline sponge. After the graft is prepared, we'll get back to the knee and start our preparations for ACL tunnels. Speaker  I like to drill my femoral tunnel through an Anteromedial portal approach with the knee hyperflexed. We'll drill our drill pin in place, and then we'll ream with a low profile, rigid reamer to the depth of about 22 to 23mm. The size, depending on the size of your graft. And we'll go ahead and pass a passing suture. Next we'll assess the integrity of our femoral tunnel from the medial portal. Next we'll go ahead and drill our tibial tunnel using the FlipCutter. This allows us to create an all inside ACL reconstruction using the low pro rigid reamer on the femur and the FlipCutter on the tibia. We retro reamed to a depth of about 25 to 30. Again with the size based on the size of your graft. We'll go ahead and pass a passing suture. We'll collect both passing sutures for the femur and tibia. And now we'll get ready to pass our graft. Our graft has been previously prepared. Soaking with vancomycin soaked saline under tension on the back table. Now we'll get ready to go ahead and pass our graft. And first we'll pull up into the femoral tunnel. Through the femoral tunnel, we'll pull our leading blue FiberWire sutures, as well as the TightRope white sutures through that cortical hole on the femoral tunnel, which can be 4 or 4.5 millimetres, depending on your preference. Lots of options for you. Speaker  You'll see we're elongating the TightRope soft button by pulling on the blue leader sutures out laterally against the white TigerWire sutures out the medial portal, and that elongates the button. You see me switching my scope over to the medial portal to watch that soft button go up into the femoral socket, and then go through that cortical hole on the lateral femur. Again, you're drilling that typically with a four or a 4.5mm reamer, or you're using your FlipCutter to make that hole on the lateral cortical wall. Here, we're going to watch that TightRope go into that cortical hole, and then flip just on the lateral cortex of the femur. And we're doing that by keeping the button elongated by pulling on those TigerWire and FiberWire sutures. Now that we've flipped our button, we can pull back on the graft InternalBrace or both, as you see me doing here. And really make sure that button is tight against the lateral femoral cortex. I like to take an X-ray intraoperatively with the mini fluoroscopy to confirm the appearance of the button. And the versatility of the soft button is that if I don't like anything, I have an opportunity to adjust the soft button before I tension my graft. We like the position of our button. We're happy with everything. So now we'll get ready to bring the graft up into the femoral socket. Speaker  Here, I'm marking the TightRope sutures with a sterile marking pen so that I know I'm keeping my TightRope even. Next, we don't have to worry about the blue leader sutures or the TigerWire trailing sutures. Those are done at this point, and we're simply going to use our tightrope sutures to shuttle our graft up into the femoral socket. I like to get about 15 to 20mm of collagen up into the socket. And then I know that I have a really nice biologic tight fitting construct in the femur. Next, I will elongate the soft button by pulling on the blue leader FiberWire sutures against the white trailing TigerWire sutures to elongate that button. So now that we've secured the graft into the femoral socket, we'll go ahead and pass the graft into the tibial socket. We will use the FiberSnare that we previously collected out the Anteromedial portal to pass all of our sutures on the tibial side of the graft, including the InternalBrace FiberTape sutures down the tibial tunnel. As you can see here, I've already passed all of those sutures down. So now we're pulling all of the sutures down the tibial tunnel to maintain the elongation of the soft button. We'll leave our TigerWire sutures out the medial portal and we'll pull opposite those the leading blue FiberWire sutures as you see here just like we did on the femoral side. Speaker  And then we'll pull that. We'll pull tension on those two sutures, and then we'll be able to pull our button through that tibial tunnel through the FlipCutter hole. Next, we'll discard our TigerWire sutures because we no longer need them, because our buttons are where we like them. Once we've secured our graft into the tibial socket, we'll go ahead and cycle the knee 10 to 15 times, maintaining tension on the graph the entire time. And then we will begin our tibial fixation. Here I'm showing the features of the TightRope soft button. We're elongating the button using the TigerWire sutures against the FiberWire sutures. We no longer need to do that at this point because the button is outside the cortex. But just illustrating how this works. Once you're done with the elongation of the button, you can discard the FiberWire and TigerWire sutures as you see here, because we no longer need to elongate the button. Next we will go ahead and tension our ACL graft just a little bit. Not all the way because I like to tension my internal brace first. But here I'll get the button down about 8,090% just basically. So it's resting on the cortex. But I like the graph to be tensioned last. So we'll do our final tensioning later. Next we will go ahead and secure our internal brace FiberTape sutures. Speaker  We'll drill. Then we'll tap the cortical bone. And then we'll place the FiberTape into a 4.75 SwiveLock suture anchor. And we'll get that down just distal to the tibial tunnel aperture. Now you can see I'm final tensioning the graft using the TightRope soft button on both the tibial side, and I have the opportunity to do that on the femoral side as well. I typically do that with the knee at about 10 to 20 degrees of flexion, and I do my internal brace at full extension or full hyperextension. Next we'll go back to the scope. We'll make sure we love the appearance of our graft. We still have opportunity to retension our graft on either the femur or the tibial side using the TightRope soft button technology. You can't see the internal brace FiberTape, but they are resting behind the graft in this case. We'll then final check our exam with an intraoperative lachman and we really have no motion in this case. Just finished up with surgery. Acl reconstruction quad tendon. Autograft. Fibertag. Tightrope. Soft button on both the femur and the tibia. Internal brace. As you can see here on the intraoperative fluoroscopy X-rays, we can see the TightRope soft button on both the femoral and tibial sides. Looks amazing. Super excited about this technology and can't wait to see this athlete get back to sport.

Live Case: TightRope® SB Implant and Quad Autograft for ACL Reconstruction

Lee Hunter, MD (Columbia, TN), presents the Arthrex Elbow Fracture Plating System, using a dorsal olecranon fracture plate to reduce the fracture. The elbow is positioned using the ElbowLoc® arm positioner, allowing the surgeon to complete the surgery in supine, as shown in this video, or lateral position. KreuLock™ locking compression screws allow for compression across the fracture and stability in the plate.

Hand and Wrist

Olecranon Fracture Fixation Using the Arthrex Elbow Plating System

My name is Lee Hunter. I'm an upper extremity orthopedic surgeon with Tennessee Orthopedic Alliance. So we've chosen to repair this elbow fracture using this elbow lock arm positioning system. And it's perfect for a lot of things elbow related, but particularly olecranon fractures because, say, for example, now we have this patient's arm at 90 degrees, and there's some inherent tension on this proximal fragment from the triceps. How you reduce that tension as you extend the elbow. And what that does, it just makes maintaining the reduction a lot easier. Today we're using the six hole proximal ulnar olecranon plate system also offers a shorter straight two hole plate. Arthritis also offers extended versions of these proximal ulna plates, all of which really nicely mirror the bow of the proximal ulna. Now, we've got our provisional fixation. My assistant's not really doing anything because elbow lock's doing all the work. We generally start with this oblong, most proximal compression hole. It is placed by cortically. You're well anterior to the coronoid process. We've got these nice ratcheting screwdrivers with an ergonomic handle which is really nice. Generally the oblong screw first and then one of these proximal screws just kind of dealer's choice on those just to make sure you got both fragments stabilized. So this is what I like to call a point and shoot guide. It could also be called a calibrated drill guide. And it's really done a fine job with this. As you drill and you advance, the single etching actually refers to the shorter screw lengths that are in this image on the top. And as you keep drilling and you advance the drill bit, you'll notice a double line comes in and that actually references these longer screw lengths. So as you put in these proximal screws, you just keep in mind where your joint is. Now we can see it through this window that we've made. Be cognizant of that with these proximal screws. What I'm trying to do with this is I'm trying to aim obliquely, staying in the proximal ulna, but engaging this good coronoid bone up here because a lot of times the bone just distal to that is not quite as good a bone as in the coronoid process. This is what all these proximal screws are trying to aim and get up in. I would like to point out, as you're exposing, these proximal ulna fractures, leave as much soft tissue attached to the bone as you can. I've left this sleeve of soft tissue here purposefully because my ulnar nerve is protected from that. Always be aware that sometimes there's metaphyseal comminution here. So there is. I would encourage you to strip this more, to expose more where you can actually see the interdigitation of the fracture fragments. And after we after we lock the plate, after we put this screw in, we'll have the plate secured to the distal fragment. And we'll image and make sure that we're happy with our reduction and our proximal most screw. And I would suggest that before you get too committed to this kind of temporary fixation that we have, that you bring in fluoro and make sure you're happy with your reduction and your placement of these initial screws, particularly this proximal screw, and how we image with the elbow lock system in this situation is you loosen the humeral collet, you just slip out the humeral brace, and the surgeon abducts the arm off the table, and you bring in fluoro from the side. If you notice this lateral view that we have the elbow, you'll see a few things. The plate fits really nicely on the back of the ulna, particularly proximally. There it does over the olecranon that proximal most screw, how it survives right under the joint surface and engages that really hard metaphyseal bone at the base of the coronoid. That's really what you're after. And that's my temporary fixation. Right below that, there's another screw that's going to mirror that course as well. And you can see really nice position of the distal screws. So now we're happy with our reduction. We know our plates right. We don't have to change anything. We can just place the rest of the screws. We've removed our provisional fixation. Now we're moving on to securing the plate to the proximal ulna. This proximal most screw is oriented relatively longitudinally. So this apical screw is actually going to be quite a bit shorter. You'll bump up against the articular cortex of the olecranon, but just don't perforate it. This is another one of those oblique screws that's designed to advance up into the metathesis of the coronoid. And keep in mind, as you begin to do this, you're after two cortices. If you feel four, you're in and out of the proximal ulna and into the distal humerus, which can easily happen. So maintain some awareness of where your joint is and the inclination of your drilling. So for the purposes of this presentation, we won't fill all the holes. But you get the concept a really nice reduction. We've got really good purchase for solid screws proximally and for distally. So we'll again for imaging we'll slip off this humeral support. And the surgeon or their assistant will just abduct the arm off the table. Bring in fluoro from the side. So now this is our final reduction. This looks really nice. You know the fracture is reduced. All the screws have a really nice length. Those two oblique proximal screws that just go kind of almost juxta cortical engage that coronoid fragment proximally. That's really what you're after. And I particularly like that longer first proximal screw just immediately distal to the fracture. How that really engages the bulk of it. So I'm really happy with how our X-rays look. I inserted this proximal most screw using a variable angle guide. But alternatively you can use this fixed angle guide threaded in. And it gives you the longitudinal orientation that some people refer to as a home run screw. So here are our final images. Again. Really nice fit of the plate to the bone. The screws are all placed really nicely. You can see the home run ish type screw there proximally, just a butting up against the distal cortex which is really what you want.

Olecranon Fracture Fixation Using the Arthrex Elbow Plating System

This animation demonstrates the steps of the interlaminar approach for a discectomy procedure using the SynergyID™ imaging system and a spine-specific endoscope. It also highlights the unique WishBone™ instrument handle, which is designed for improved ergonomics, and FlexTip electrosurgery probe.

Interlaminar Approach for Endoscopic Discectomy Procedures

Arthrex interlaminar endoscopic approach for a discectomy is an ultra minimally invasive surgery ideal for patients who have been diagnosed with a paracentral lumbar disc herniation. In this procedure, the endoscope is used to assist in the approach for access and visualization, place the patient in the prone position and use a c-arm to verify the correct level being treated. Using both AP and lateral images based on the preoperative MRI, use a six step approach to complete the procedure. Step one the bulls eye. Use a switching stick to identify the entry point, which is the lateral aspect of the ipsilateral interlaminar window. Make an incision between 8 to 10mm through both the skin and fascia. An alternative method utilizing serial dilators can also be used. Insert an introducer needle. Remove the stylet and pass a guidewire through the cannula and then remove the cannula. Insert serial dilators over the guidewire until the appropriate diameter is achieved. Continue utilizing dilators for steps two and three. Step two the click. Use fluoroscopy and insert the switching stick into the interlaminar window and on top of the ligamentum flavum. The tip of the switching stick is used to traverse the inferior edge of the lamina in a caudal to cranial direction. This action should create a tactile click, as the tip of the switching stick comes over the edge of the lamina. Insert the cannula over the switching stick, then remove the switching stick and insert the endoscope. The surgeon may choose to connect the cannula holder to aid in maintaining the trajectory. Connect the holder to the cannula prior to the switching stick being removed. A depth stop may be attached to the endoscope to maintain the depth within the cannula. Arthrex offers a unique WishBone handle design that allows for improved ergonomics and mobility of the instrument by the surgeon. Step three cleaning the trampoline. Once the endoscope has been inserted, insert a series of grasping instruments and the electrosurgery probe through working channel of the endoscope to remove excess tissue and coagulate blood vessels to expose the ligamentum flavum. Step four. The black hole. Use both the straight and angled scissor punch instruments to resect the ligamentum flavum, and to gain access to the spinal canal, which will present itself as the look of a black hole. This is caused by irrigation fluid moving into the spinal canal, creating negative pressure on the Carta equina, thereby expanding the epidural space. Step five. Identify the edge of the nerve root. Once a sufficient amount of ligament has been excised, slowly advance the cannula through ligament and into the spinal canal, with the bevel of the cannula facing medial and allowing the edge of the nerve root to be clearly visualized. Step six. Retract and protect. Mobilize the nerve root by using instruments such as a blunt tip, elevator nerve hook, and articulating probe to release any scar tissue that may be adhered to the dura. Once the nerve root has been mobilized, advance and rotate the cannula to retract and protect the nerve root. With the nerve root retracted and protected, use a blunt instrument, such as an elevator, to put pressure on the annulus, releasing the nucleus. Pulposus. Next, use grasping forceps to extract the exposed nuclear material. Use the Electrosurgery probe to ablate nuclear material and minimize the annular defect. Once complete, slowly remove the scope and cannula.

Interlaminar Approach for Endoscopic Discectomy Procedures

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.

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