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

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MBT as a Definitive Solution After Temporary Relief From Radiofrequency Ablation

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

MBT as a Definitive Solution After Temporary Relief From Radiofrequency Ablation

Neal ElAttrache, MD (Los Angeles, CA), demonstrates an MCL reconstruction using a gracilis tendon autograft and the InternalBrace™ technique. Dr. ElAttrache also provides surgical pearls for anchor placement and incorporation of the InternalBrace technique.&nbsp;
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.&nbsp;

MCL Reconstruction With Gracilis Autograft, Knee FiberTak® Anchors, and InternalBrace™ Technique 

Hello, I'm Doctor Neil Alatrash from Los Angeles, and we're going to demonstrate a medial collateral ligament reconstruction and internal brace technique using gracilis tendon autograft and the knee fiber tack anchors. The equipment necessary is the atraumatic hamstring harvester, the fiber tech instrumentation and fiber tacks, and the instrumentation for the 4.75 swivel lock. We have a left knee specimen, and to expose the injured medial collateral ligament and harvest the gracilis tendon, we've made an incision over the medial side of the knee, extending from the medial epicondyle down to a position about three fingers below the anteromedial joint line on the tibia. So you're going to be at the top of the sartorius fascia, the anserine tendons. So we have an incision and dissection of the soft tissue being careful to protect any major branches of the Infrapatellar branch. The saphenous nerve. We've already made an incision in the crural fascia of the knee, and it's beneath that fascia that you'll immediately encounter the medial lateral ligament. We've carried the incision on the fascia down to the sartorius expansion. And just beneath that, the most superior tendon will be the gracilis tendon. To isolate the gracilis tendon for harvesting, we want to keep it attached to its anatomic attachment on the anteromedial tibia. It will be the most superior of the hamstring tendons and directly underneath the sartorius. Expansion, easily isolated. When we get to this layer, we want to be able to bluntly spread and separate a nice path that we'll use for our tendon harvester. Utilization of this gracilis is very user friendly because you don't have to make any separate incision you're going to be able to visualize it through the same incision that you would use to fix your MCL. Now would take a stay suture or Penrose to isolate the gracilis. And then just using your clamp and not scissors, just go ahead and strip up along the tendon. That will detach any firm tendon as fibrous attachments to the gastroc. As you make the turn next using the atraumatic tendon harvester, apply that to our tendon. If you feel any adhesions, then you can simply get underneath the sartorius expansion. And this atraumatic harvester is just like it sounds. It will not prematurely cut off your tendon. Okay, so that's our graft. You really won't know how long of a graft you need, but keeping it attached to the tibia really helps you to control the graph. So you don't have just a free graft you're working with. You don't have to make any drill tunnels that you have to insert the graft. So now we just find the course of the MCL. And MCL is right here going from the medial epicondyle attachment which is here. Here's the anterior border of the MCL, the posterior border of the MCL, and then the fanned posterior oblique ligament behind that. Now we're going to use the drill for the fiber tac anchor. And on this put an anchor immediately at the anterior border of the MCL underneath the sartorius expansion. Since the bone here is cancellous. Going to unwrap those stitches before you pull back on the guide. That will make sure that the bone isn't so hard that you dislodge the anchor. After that is out, then make sure that you set your anchor. Just take that. Stay stitch out of the loops of the stitches in your graft with the anchor well seated. We'll go ahead and place a clamp through both loops of the anchor. We'll pull our gracilis tendon through those. Then, holding tension on the graft, we'll go ahead and secure our loops around the tendon. And we're going to leave those sutures uncut. At this point, I'm going to just make sure we have enough length with this tendon. We have plenty of length. This stage, we would put anchors in along the direction of the native MCL distal to the joint line. What this will do is it will reproduce the attachment of the deep MCL. And for this we separate those stitches. Now, in the post-traumatic situation, this MCL is going to be torn in some fashion. It's either going to be shredded in its mid substance, it's going to be avulsed proximally or avulsed distally. We take this stitch and we're going to go through the substance of the MCL all the way to the posterior border. If the pol is torn too, you can grab some of that as well. So what we're going to do this in mattress fashion. And we save these stitches. Now at this stage we find our attachment. And once again then we make our drill at the attachment for the MCL. To accommodate the double knotless stitch. And then set your anchor. So with the stitch identifying the loops, you can go ahead and separate those loops and then discard the stitch. Now at this stage then we bring our gracilis tendon autograft through those loops again. We have the knee flexed at about 30 degrees, and we have it in a slight figure four position which is closing down the joint. So it's actually reducing the joint with tension applied then to the graph pulling proximally. We go ahead and tighten that down. Once again we'll leave these long for now the MCL to find the proper site of attachment from anterior to posterior on the tibia. The posterior border of the MCL is even with the posterior medial border of the tibia, so that's easily palpable, which is right here, and it's more posterior than you think. So to put this final anchor in, you need to be directed slightly anterior so that you stay in bone, because we'll add an internal brace along with this. We need to measure where we want to attach it. Mark the tendon. We'll use number two fiber wire. And we'll put a Krakow stitch in for about a centimeter in length. We've placed our Krakow sutures over the distal centimeter of the graft and left the stitches long, because we're going to use those stitches to finally fix the graft into its position. And this is a very versatile, because if there was a distal rupture of the MCL that you wanted to add this augmentation, then you could suture the native ligament and use those sutures into the same fixation with the swivel lock as the sutures from the graft. In this situation, what we're going to do, we're going to imagine that the MCL was very deficient and traumatized over a wide length like it often is, and we're going to use the stitches from our proximal anchor as our internal brace sutures. So we find the attachment point and we'll mark that the marking pen. And then this is our our drill for the swivel lock. And then we'll go ahead and tap that as well. So we'll amputate the graft but be a little bit generous and leave some there. So we put all those sutures through the eyelet of a 4.75 swivel lock. And your priority right now is to tension the graft. So take the stitches from the graft and hold those tight. Just take the slack out of the IB stitches. Once you get it started and you're under good tension, then you can just let those stitches go and we fully deploy it. Make sure that we're buried in bone. Nothing proud. And I would save these two. So we have our stitches from from the first loop that we put in that we passed our graph through. Make sure that that that has stayed tight so we can post tension that the stitches that you see here, this is the suture tape, sutures that come off of our proximal anchor. And that's going to function like our internal brace. And we properly want to have that internal brace fixed along the posterior limb of, of the graft, which is the posterior border of the MCL. That way you're going to get full range of motion back. And you'll be able to prevent any laxity in flexion. And we have here we have our graph fixed. Now since we have this late inside the the anchors that we put, we can tie and repair the MCL just distal to the joint line around both limbs of the graft. So we have our internal brace sutures through the eyelet of the swivel lock distally, and we have the central core stitch from the swivel lock. So we'll tie the sutures from the end of the graph to the central core stitch. This further locks the fixation of the graft sutures. And that's our reconstruction. We have both limbs of the graft tension nicely above and below, and also repaired to the native ligament itself. This has been placed anatomically, so it should permit full range of motion with extension and flexion. Once again, you can use your graft and the repaired and supported native ligament as your fixation strut. If you need to tighten the posterior medial capsule and posterior oblique ligament to that. Now, if there has been proximal damage to the ligament near the epicondyle proximal to the joint line, another suture anchor can be added using the fiber tack, once again going through the native collateral ligament complex, even through the medial patellofemoral ligament that sometimes is damaged as well, and so those then can be incorporated into your autograft and native ligament repair and augmentation. So there you have the reconstruction and augmentation of medial collateral ligament with the gracilis tendon autograft and internal brace technique fixation. After we've checked the range of motion and stability, the wound is then closed with a multi-layer closure, closing the deep fascia of the knee and then the subcutaneous tissue and skin.

MCL Reconstruction With Gracilis Autograft, Knee FiberTak® Anchors, and InternalBrace™ Technique&nbsp;

Designed to provide anatomic contour with precise instrumentation, the Arthrex Proximal Tibial Plating System features 4 unique plate styles, equipped with advanced variable-angle locking capabilities and KreuLock™ locking compression screws, to optimize treatment of proximal tibial fractures.

Arthrex Variable-Angle Proximal Tibial Plating System

Arthrex Variable-Angle Proximal Tibial Plating System

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

AC Repair Using FiberTape® Cerclage

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

AC Repair Using FiberTape® Cerclage

During Spine Evolutions, Chad E. Campion, MD (Germantown, TN), discusses patient selection criteria, literature support, and surgical techniques for the treatment of grade I spondylolisthesis via endoscopic decompression.

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Surgical Strategies for Endoscopic Decompression of Grade I Spondylolisthesis

OrthoPedia: Surgical Strategies for Endoscopic Decompression of Grade I Spondylolisthesis

The Arthrex ElbowLOC® positioner is a modular, upper extremity positioner that gives the surgeon the choice of supine, lateral, or supine-suspended positioning for elbow surgery, as well as a wrist traction device for wrist and hand arthroscopy. The ElbowLOC positioner is easy to use and set up, and housed in a space-saving single autoclavable tray.

The Arthrex ElbowLOC® Elbow and Wrist Positioner

The Arthrex ElbowLOC® Elbow and Wrist Positioner

Brian D. Giordano, MD (Rochester, NY), describes a case in which he treated a 32-year-old laborer with a full-thickness chondral defect in the acetabulum using the AutoCart™ technique, a single-stage cartilage repair technique that combines platelet-rich plasma with collected articular cartilage and BioCartilage® extracellular matrix that can be performed concomitantly with other procedures.

AutoCart™ Technique for an Acetabular Chondral Injury

Hi, I'm Brian Giordano from the University of Rochester Division of Sports Medicine and Hip Preservation. And today I'm going to be talking about acetabular chondral injuries treated with auto cart. So the case that we're discussing today is a 32 year old laborer who had experienced about 2 to 3 years of hip pain. This began initially when he was stepping awkwardly off a curb. He went through a period of dedicated conservative care and rehabilitation, but unfortunately was unable to improve. He gained about a week to two weeks of relief from an ultrasound guided intra articular steroid injection. He was noticing painful mechanical symptoms with loaded rotation, and that pain had affected his activities of daily living, in addition to his work and also strenuous labor. And of note, this was not a work related injury, so clinically this individual had an antalgic gait pattern. He walked with a shortened stride length indicating some capsulitis. The arc of motion was limited and inflamed. He had pain at 90 degrees of flexion, exhibiting about ten degrees of internal rotation and 45 degrees of external rotation. He had positive provocative findings for impingement, fader and faber and reactivity on anterior and lateral impingement testing. So when we got standard series of radiographs, what we can see is a classic pattern of of superolateral Cam deformity with reduced femoral head neck offset. There was adequate preservation of joint space with no obvious advanced degenerative changes such as subchondral cysts or sclerosis. On a lateral, we see a small acetabular rim fracture characteristic of more of a mixed type of FAI pattern, but nothing that would preclude his candidacy from arthroscopic hip preservation surgery. When we look at advanced imaging again, no concerning warning signs, there is some cortical irregularity at the anterosuperior acetabular rim and a large Cam lesion. And in our in our hands, when we can send a patient like this for surgery, we're often consenting them for the possibility that they may need a biologic adjunct to their treatment. We can send them both for the possibility of of microfracture, as well as the possibility of auto cart. So what we can see from this video is a full thickness chondral defect in the weight bearing aspect of the acetabulum. This is the large acetabular rim fracture which is being removed. There was also an addition a partial thickness articular lesion which we sometimes term a PTA lesion. And so you can see in standard fashion we're recontouring the acetabular rim back to a nice flat stable plane. And we have a little pocket here. The pocket does not communicate with the intra articular space. So we're able to actually create some marrow stimulation with a curved bone cutting shaver. And in addition we can use a microfracture tool to stimulate a biologic healing response. In this particular case, we felt that there may be additional advantage that we could gain by using a bioactive substance, such as auto cart, to reproduce the natural matrix of subchondral adherence. We're using a a ring curette to fully debride and prepare the the more central acetabular defect and a curved bone cutting shaver to promote a really favorable and brisk biologic healing response, which you can see here in the hip. Sometimes a microfracture tool can have a poor vector. The bone can be extremely sclerotic and hard, and sometimes that's challenging. But a curved bone cutting shaver works particularly well for that in this. In this case, I passed and looped all of my sutures first without without actually securing or tightening them right off the bat, because I wanted to leave some space to insert our biologic healing matrix. You can see that large Cam lesion and that Cam lesion is filled with bioactive cells which which are in a state of bioactivity. They can be harvested and incorporated into a matrix of bio cartilage and whole blood, ACP or PRP to create a really nice flowable material, which you can see being delivered with a cannula. This is then done in a way that does not overfill the lesion, but but using specialized tools or elevators. This can be smoothed and really used to fill the entire geographic border of the lesion. Now you're seeing the same substance being injected underneath the labrum and cartilage into the partial thickness lesion. It's now being stabilized with with a fibrin glue matrix. And finally, at the conclusion of the case the sutures are going to be secured. The loops are going to be tightened. Capturing and protecting that biologic substrate within the lesion. And finally the suture limbs are cut. The femoral head is reduced after an appropriate period of maturation time. So postoperative rehabilitation included a multimodal intra articular cocktail block, which is comprised of ropivacaine, morphine, and toradol. In our practice, we believe in immediate post-operative rehabilitation, active mobilization, circumduction, and stationary bike use. Structured physiotherapy program under the direction and care of an experienced sports hip physical therapist. We start with a period of about £20 foot flat touch down weight bearing for four weeks, progressing to weight bearing as tolerated by about six weeks. We often implement some aquatic therapy by two weeks, and add myofascial therapy to enhance some of the soft tissue envelope and the healing response. Around six weeks, we add progressive strength and endurance, work through 6 to 12 weeks, and then eventually advance to low impact cardio and progressive progression back to running and sports specific conditioning as the patient is able to tolerate it. And this is a very personalized and individualized plan that can vary patient to patient. In this particular case, we had returned back to the Or around three years after the index surgery for an unfortunate re-injury. The patient had been doing well up until this re-injury, but unfortunately in the work environment sustained another injury which required a period of rest time away from work, physiotherapy and injection that unfortunately was unable to gain enough symptomatic benefit that he was able to fully heal. So with that in mind, standard post-operative imaging was was taken reflecting some capsulolabral adhesions, and so we returned back to the Or to address the capsulolabral adhesions, but also at the same time, assess his cartilage, repair his labral, labral tissue, and also any bone work that was done at the time of the first procedure. So in summary, Auto Cart offers new advances for creative solutions for chondral injuries. The focus, from an arthrex perspective is always on repair, remodeling, normalization of native anatomy rather than replacement. It would encourage anyone to consider repair of both partial thickness or Pita lesions, chondral injuries of all varieties, and full thickness lesions as well. Auto cart allows the matrix restoration of full thickness lesions, allowing us to maintain subchondral anatomy. But I would also remind our viewers to make sure that the primary osseous deformity and the structural dysmorphology is normalized to optimize the loading and the force distribution across the graft to enable optimal graft integration and healing. Thank you very much for your attention.

AutoCart™ Technique for an Acetabular Chondral Injury

John Xerogeanes, MD (Atlanta, GA), demonstrates how to use reusable sliding GraftClamp instruments with the GraftPro® system during a quad tendon ACL reconstruction using FiberTag® TightRope® SB implants. The reusable GraftClamp instruments simplify graft preparation by allowing single-user graft preparation.

Quad Tendon Graft Preparation Using Sliding GraftClamp Instruments

We're going to take you through what we have on the table today. We have our standard Graph Pro, we have our fiber tag tightropes, these being ones with soft buttons. We have our our graph sizing tubes. We have our tenaculum scissors a graph. And then we have our new graph clamps. One of the downsides when you're preparing a graph is especially on a quad tendon, you need an assistant. We've tried to eliminate the need for an assistant, because you don't always have that extra person in the operating room. These are the new graft holding clamps, which eliminate the need for an assistant. You can see they look like a normal clamp just would come down. You can make it tight, but they have a sliding feature on the back. This hooks on and slides back and forth. What this allows you to do is pass a looped graph without pulling this out, or not having or allowing your assistant to pull it around the graft. So there's two types. This is the part for we used to hold the graft. And this is a part that we use to hold the card on the graph. This one is just like a normal tenaculum. And I'm going to grab the normal tenaculum that you see. And you see this one that has a little slot right here for the card, and you can hold your graft. And this is the one your assistant used to hold. Now we're going to eliminate your assistant and use the card here. Hold the graft. And then this will be under tension to hold the graft tight while you make it. So to put this on, you go 90 degrees, hook it and then you're you're you're hooked. You can see where the arrow is, which tells you which direction you're pulling and you slide over. And in that slot you can move your suture. So we've just harvested our quad tendon graft. You have the loop suture that we used on the distal portion of the graft to pull it through the Quad Pro, and when we prepare the graft, we always want to prepare the tibial side first. And that's always the proximal portion of the graft. Because this is the most severe part of the graph that you have to tubularize. And it's the most inconsistent. So the first thing we need to do is stabilize the graft and hook it to the back part. And now we have the graft hooked nicely. I often will come back here and cut this. So we keep these extra sutures out of the way. So now we'll take both posts and place them in the graft pro. You can see the arrows at the top here telling you which direction that the tension is going to go between these two. And now what we have to do is take this graft and put the the fiber tag tightrope on. So we'll grab the tibial side. We unwind this from the card. And just like we used to use the tenaculum, we're now going to use our tenaculum clamp. And again here it slides in. You can see it holds it perfectly. So put that in the middle. And you find your distal end of your fiber tag and you pop it through. So just like you would a tenaculum clamp. Now we take our graft, put the distal part in, we pinch it and slide it down. Now that we have our graft loaded onto the clamps, it can easily be transferred to the Graph Pro. Remember, you have to come in at 90 degree angle to get the clamp on. So leave a little bit of wiggle room here that you can go in. And now that we have it set we can put tension on here and we're ready to go. Usually when you're preparing a graft, your assistants are pulling tension on the part with the card on it. When you do that, the assistants often across from you. So we find it easier to change the angle of your graft pro so it holds it like this. All right. So now we're going to put the fiber tag on the proximal end of the graft. As you know the fiber tag has many advantages. The greatest advantage is its cyclic strength is incredible. So you don't get cyclic deformation like you do on regular sutures. Secondly, it's a much faster way of preparing the graft with less suture load. So we hold a little, we hold tension. And again I don't need an assistant holding tension I come right through. I hold my finger on the fiber tag and I pull this so it's nice and flat. Okay, now I slide back this way and again. Many times you would you would have to lift this out and go underneath to pass the suture loop. We don't have to do that anymore. All we do is pull up underneath, slide over and come out. And now this is ready to put my next suture in so you can see it's much faster. You save time and you don't need an assistant. So I'll show you that one more time. We pull tight. We separate. We come underneath. We use the suture to pull over. We come out and now we're ready to do our next throw. Now we're ready to lock the fiber tag. Tightrope construct in place. So we come underneath through the hole, and then we come down right next to that point. And again you see the tension that this holds for us. So it makes it very easy for us to pull tension. Now you could also pass from the opposite side. So if you're left handed it's often easier to pass from left to right. Then you can use your your left hand to put the needle through the tendon. So in this case again you pull up and under you slide across, you come out and you're ready to place your last piercing. So we go through, we come down, we tubularize the graft. Now, when we. If we want to come back, if you're ambidextrous, you can come back, go up and over, and then you don't have to slide things back and forth. And now we tie the sutures. Now, this is a very flat, lying suture. Some people like to bury the knot. I tend not to, because I think it's just not very big. So we get a nice flat knot. And then we cut the end and we're good to go. So now that we've prepared one end of the graft, you can take the tenaculum clamp off and use it to hold the other end of the graft. We secure this with the traditional alligator type clamp. Be careful that the clamp itself grabs only the card and not the sutures between the card. You don't want to damage any of the sutures, so grab the card itself. So now we're going to prepare the femoral side of the graft in a similar fashion that we did the other side, we hold tension on the fiber tag we come down through. And we get this place nice and flat. So now that we place the fiber tag, we have two options on how we want to pass the sutures. We can pass closest to us like you saw on this end of the graft, or we can pass away from us. So to pass away from us, we pull under the graft. We slide the suture Over. We push over. And we're ready to pass. Now, you saw one of the reasons why I don't love it this way. Because it can get caught on the card. But you have personal preference. And if you choose to pass it that way, it will work on either side of the graft. And again, I'll show you one more time. So again, if we go proximal, if we go to the top part of the graft, we come in, we hold over and we come underneath. And if you pull tension on the graft, you're able to avoid grabbing the card. So again, it works either way. It just has to do with personal preference. So now we're ready to tie. We take the needle off the graft suture and we're going to. Again put a nice flat. Not here. And this suture ties very flat. So it's not bulky at all. Again make sure you're tying a square knot here. And then your graft is ready to put in the graft tube and place in the patient. We prepared this graft just like an assistant was helping me. Some people feel more comfortable with the graft perpendicular to them. And you can certainly do it this way, because, again, you don't need an assistant holding a graft off to the side. It's again your personal preference.

Quad Tendon Graft Preparation Using Sliding GraftClamp Instruments

DynaNite® CT nitinol staples deliver active compression for secure sternal closure, applying proven orthopedic fixation principles to cardiothoracic surgery. With two low- profile staple size options, the system offers flexibility to accommodate patient anatomy and surgical technique. Engineered to ensure consistent sternal stability throughout postoperative recovery, DynaNite CT staples work in combination with FiberTape® cerclage to deliver a comprehensive solution for sternotomy repair.

DynaNite® CT for Sternotomy Closure

Low profile Superelastic dynamite CT. Nitinol staples are available in two sizes, designed to accommodate a range of patient anatomies before closure. Measure the thickness of each sternal have to ensure secure fixation without compromising the posterior cortex. Choose a staple that is at least two millimetres less than the thickness of the sternum. With fibertape sternal closure completed, the dynamite drill guide is then positioned centered and perpendicular, setting the stage for precise implantation. The dynamite CT system features a specialized positive stop drill bit designed to safely drill into the sternum, preventing overpenetration to protect underlying tissues using the loading device. The dynamite staple legs are adjusted to match the width of the drill guide. The staple leg should be in parallel or near parallel position to facilitate compression of the sternotomy once inserted. Once seated, the device is released, allowing the nitinol to return to its original shape, delivering targeted active compression to the sternal body. A tamp ensures the staple is fully seated. Additional staples can be placed as needed as an adjunct to fibertape sternal closure. A minimum of two staples is recommended to optimize fixation and enhance resistance to lateral distraction of a median sternotomy. Dynamite CT, nitinol staples and the Fibertape sternal closure system deliver the strength, compression, and flexibility needed to optimally personalize sternal closure for every patient.

DynaNite® CT for Sternotomy Closure

Carl T. Hasselman, MD (Pittsburgh, PA), demonstrates the BunionBrace™ surgical technique to augment and reinforce a direct repair to the medial capsule during hallux valgus correction. In this case, the procedure was performed alongside a Lapidus procedure using an I-beam plate. The BunionBrace technique aims to reduce the chances of recurrence of a valgus deformity at the MTP joint. Weakness in the joint capsule can be a mechanism for recurrence of the deformity. Augmenting the capsular repair using the BunionBrace system aims to increase the strength of the primary repair.

BunionBrace™ Medial Capsule Repair Surgical Technique

BunionBrace™ Medial Capsule Repair Surgical Technique

Rachel M. Frank, MD (Denver, CO), demonstrates an all-inside quadriceps ACL reconstruction using the FiberTag® TightRope® SB implant with the InternalBrace™ technique.&nbsp;
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.&nbsp;

All-Inside Quad ACL Reconstruction Using the FiberTag® TightRope® SB Implant With the InternalBrace™ Technique 

I am Rachel Frank, a sports medicine surgeon from the University of Colorado in Denver. This is the all suture ACL reconstruction technique. No metal, no peek. So we will now demonstrate our soft button quad link ACL reconstruction. Here I'm going to demonstrate the harvest through a vertical incision. But you could certainly do a transverse incision if you're more comfortable with that. And we'll make our incision. And then during the incision and exposure one of the most important parts is to get rid of some of this subcutaneous fat. That's how you can keep your incision small while still getting good visualization. We've excised some of the fat, and we're kind of looking down on some of the peritenon on top of the quad. I'll take the Cobb elevator and I do an initial sweep and a second. We're going to switch to the Army navies. An initial sweep of the tissue. And then I'll switch to the Army navies once I take a sponge and get that in there and get really some of that soft tissue off. So then we have a nice view of the quad here straight down. And then what we'll do is we're going to take the scope and a marking pen so we can see the quad coming up. And basically I'll go right there and then I will relax my army Navy I'm going to take it out. I lever my scope up and then we can feel and see the light and we'll make just a little dot. And now I know where to aim to. I'm pulling these quite distal. I'm going to take my quad pro. In this case we're using a size ten. We've marked the end of the Quad Pro with a purple marking pen. And that's going to give us the postage stamp. And I'll start that basically on the superior pole of the quad. You can see in there I'll take the 15 blade knife back. Thank you. And then the pickups, then the Alice. And then one of the pearls here is to stay on the inside of your mark so that you don't harvest too big of a graft. And I do a full thickness harvest. I'm harvesting this right off the superior pole of the of the patella, and I'll actually take my knife as far as my incision allows before I start with the Quad Pro, and then we'll use our suture tape fiber loop next. And sometimes there's a little synovium underneath. So you just have to try to get that away with the knife. So we use the 15 blade as mentioned to harvest the graft from distal to proximal as far as my incision allows. And then we use the quad Pro to finish it up. Here we'll prep the distal aspect of the quad with the fiber loop. And you want to get this nice and tight because this is what's going to be going in the quad Pro. So we have the quad Pro harvester. We'll take the needle from our fiber loop and put this in the tip. And we'll use the weight of the needle to just fall through the harvester just like that. And then this quad pro can be used. You slide this along the quad for as long as you've harvested, and then you're going to go in 360 degree loops either clockwise or counterclockwise. And it's a push pull fashion. Staying parallel to the shaft of the femur. So you can see it's nice and calibrated. Here. I'll turn that up. And my goal is a 65 to 70 graft for nearly all of my patients, from five foot 2 to 6 foot two. If they're a little shorter, I go a little shorter. If they're a little taller, I go a little longer. And then I'll take the graft, keeping it in the window of the quad Pro, pulling the needle back, and then we'll move the Quad Pro without spinning now up because we've already done our cut. And you can see calibrated here. We'll go ahead and take the pushrod insert this in. And again I'm going to do a double check here on the calibration. Make sure I really like it. And I'm holding firm tension on the quad. And I'm doing a push pull. And I like that sound. And when this comes out this should be a nice full thickness graft. Not getting into any muscle a little muscle is okay. But you can see here this is really a nice full thickness harvest. You can see all the layers to the quad. So you can see that that full thickness harvest has been completely closed with the loop link, which again is a very strong luggage tag suture and it's very low profile. This is not going to cause any irritation to the quad tendon. This is not going to cause any irritation or adhesions to the patient. And you can see it's completely closed and there's no gaps whatsoever. So we won't get any fluid extravasation throughout this. You can see the VMO quite nicely. So really nice mid third quadriceps tendon harvest with closure. So here we have the completed quadriceps graft. Again all soft tissue about 65mm in length by approximately ten. Or in this case about nine nine and a half by circumference. And we use this all with all of our instrumentation. We harvested this all and prepped this all. So you can see the only difference here with the fibre tag tightropes is this now has the soft button. So those are the yellow buttons. And you can see those on either side. And we can see this is the femoral side. Because of the internal brace, the tibial abs side will not have the internal brace. And again these yellow portions here are what's new. This is the soft button. All suture. No metal no plastic no peek. Incredible opportunity for us to have a metal free construct for our ACL reconstruction and leave patients with a more natural knee. So now we're going to go ahead and get the graft and the graft tubes to compress it down while we get ready to drill our tunnels. So here now we're compressing the graft typically on the back table. And it's in the graft compression tubes. And we'll try to get this as tight as we possibly can so that we can make this graft as compressed as possible. Taking advantage of the quad, with its full thickness nature and the circumferential fibers, we get a nice cigar like graft, but we want to keep it as compressed as we can. So here's our flip cutter femoral guide. And we can see what's new now is we have a ten millimeter step at the end instead of seven millimeters, which makes this a lot sturdier in the bone and a lot easier to pass our soft button with respect to our fiber tightrope, we have the femoral guide in. So we'll use our flip cutter for our all inside. This is the new power. Okay. So we'll mail it in the ten millimeter step. And then we're going to open and flip. Nine five okay. And the reaming has gone all the way back to the step. And again with that ten millimeter it's just a three millimeter difference. But it provides you just enough to be able to do that without compromising the cortex, which is really nice. It's a really nice addition, small tweak, but big difference. Why don't you take a look at that and we can see our socket and then we can see our step right there, which is really nice. Really nice. All inside ACL femoral socket. So we'll go ahead and pass our snare. We'll retrieve it. Good. All right. Here. We'll take the Apollo just to demonstrate that we've marked our spot for the tibial tunnel. Tibial tunnel. Posterior aspect, anterior horn, lateral meniscus. Use the Apollo to burn that off. We'll get our flip cutter guide. For the tibial tunnel. Good. Perfect. We'll take a mallet. And again, we're going to mail it in this the new bullet here that has a ten millimeter step, which is going to make it super stable in that cortex. And then we don't have to do any math. So we'll go ahead and open the flip cutter to a 9.5. And normally I get about a 25 to 30 millimeter socket. But you don't have to do any math here. And we're just going to ream back to the step. And we're reaming just till we feel that tip of the step so that we know that we're safe on the cortex and we don't have to worry about breaching the cortex. So we'll go ahead and put the snare up and we'll retrieve it. So we'll go ahead and grab the suture snare. And I really like these snares. And it sounds a little corny, but the colors are really nice because they're contrasting the black and of course, the blue. I'm going to switch my camera to the opposite portal. I'm going to go ahead and grab my snare out the opposite portal from the tibial tunnel. Then I'm going to switch my camera back to lateral. We'll go ahead and put our passport in to help with graft passing. And then you've got the tibial side. And then we'll go ahead and get these both out the portal here. So the blue and white is for the femur. The black is for the tibia. Perfect. Okay. Good. And now we're ready for graft passage. So we're going to want to lengthen our tightrope. But you can see here the soft button is a little bit squished. So to get that nice and elongated to make it easier for passing into the socket, we're going to pull the opposite limbs of the the included tiger wire and the fiber wire. And you can see here how that goes from a ball to a nice oblong or even linear shape. To make this easier to pass through your 3.5 hole. Then what we're going to do is lengthen our tightrope. And if I want to lengthen this side here. So we have this side and this side. If I want to lengthen this side I'm going to hold on to the opposite side. Just like that. And that'll prevent this from getting. Bunched up. And then I'm going to go to lengthen the other side. And so now I'll hold the blue sutures the fiber wire. And then we'll go ahead and take the slack out like normal. And that's nice and elongated. Now we can mark it. And again, you can see here even doing that I bunched up the soft button again. So I'm going to take my tiger wire and fiber wire and pull those and elongate the button again to make that easier for passing. So I'll mark the graft here at 20. And usually the way we prep the fiber tag tightrope, it's at 20. But we'll do it. We always measure just to make sure. But yeah the end of the suture is usually right there. And if you can get 15 to 20 in each socket, you'll be perfect with a 65 or even shorter graft length. All right. So we're going to go ahead and mark our interosseous length. And we're calling that about 40. I'm going to put a dot there 3540. Good. And that's on the this is on the femoral side okay. So now we're passing our graft again. This is the internal brace side of the soft button fiber tag tightrope. But we're not going to pass the internal brace that's going to be remaining with the graft. So we're going to go ahead and pass. We're pulling on opposite limbs. The tiger coming out the medial portal and the blue coming out the lateral femur to keep the button elongated. And we're going to pull until we see our marking and kind of feel the button flip against the lateral cortex, which we just felt. And now we're going to make sure that we don't have any tension. And then now we're going to check it. And we are pulling like crazy on the IB. And I'm going to give the graft a little tug. Okay. So we're hooked against the femur. I'm going to give the ibz a little tug. Good. So you can see I'm pulling pretty hard actually. And that soft button is now bunching up against the cortex. We're going to hold tension on the IB, and we're pulling out the lateral femur on the tightrope. And we're going to shuttle about 15 up. Good I would stop there. So we have our graph passed in this femoral socket. We're going to pass everything into the tibial socket except for the tiger wire that's in both the femoral soft button and the tibial soft button. So we're passing everything, including internal brace, but we're not passing those new tiger wires because we're using those to keep the button elongated if we need. We're going to go ahead and shuttle this into our tibial socket. Okay. So now we'll go ahead and elongate by pulling the tiger and pulling the blue. And we're emphasizing here even through the whole tibial tunnel which has a turn here. I can pull on these to make that button nice and elongated. And you can see that here outside. We're going to go ahead and pass our graft into the socket. Good. And we're dunking that down. Let's give it a nice hard pull if we can because we're not quite in yet. Now we can take out our tiger wires that are in each of the buttons. So here's the one on the tibial side. We'll go ahead and just pull that out. It's served its purpose. And again its whole purpose was to keep that button elongated, to get it through the 3.5mm hole from that flip cutter bullet. And now we no longer need that. And same with the femoral side. So that one's been removed. You can see our ACL graft. Looks nice actually looks really nice. Looks really low. That's where we want it. And now we're going to go ahead and tension on the tibial side. So what I like to do here is we'll go ahead and cycle the knee. So we'd hold tension on the graft I got this. We'd go ahead and I'll take the scope out. We would cycle the knee while holding tension on the graft. We cycled about 15 to 20 times and then we get the knee nice and extended. As you can see our button here, we'll take a hemostat. We'll put it in the tightrope just to hold some tension. And then we're going to take both limbs again with the knee in extension so we don't over constrain and we'll start tensioning down our tightrope. You can see the soft button is already starting to bunch up. And I'm getting that oh that's nice nice and tight on the tibia. And then I'm going to move these out of the way. So we're going to go ahead and fix our internal brace with a swivel lock suture anchor using our power. We're going to pass our internal brace sutures through our anchor. And you can see here we've got the knee in full extension. That's really important step. And then I'm pulling tension. And then I'm just going to let it dunk right in. And then we'll go ahead and mail it this in. So then what we can do is what I like to do is I'll actually put the scope back in and I'll take a look at the graft and then we can retention. And I like to do my graph tensioning last. And what we can do here is we can see do we want to do a little more tension on the femur or tibia. And I'd like to do the femur here. So we'll get the leg back in extension. Good. Just like that a little less extension. Good right there. And then we're going to go ahead and tension retention. Look at that. We can see we're getting a little bit of creep out of here which is awesome. Good perfect. And we'll come back down to resting position. And now our graft is complete. This is rock solid. This is something I'd be happy to have in any one of my patients. And I would be very confident that they'd be able to fully return. I mean, I'm literally pulling on this. This is awesome. The other nice thing about this is there's absolutely no metal within this construct whatsoever. When they see their x rays, they're not going to see any metal in their knee. They're going to feel like this is a more normal graft. This is a more normal knee and we know that the psychologic, the mental and emotional part is just as important as the physical and biomechanical part. And all of this is incredibly strong, incredibly biomechanically robust. We're going to have a great final product. Okay. So we can see here our final fixation with the soft button. We can see that the soft button is really conformed nicely against the anterior cortex of the tibia here. Incredibly low profile. Again no metal no plastic. Really going to be a nice a nice final result for the patient. And then if I move the tightrope tensioning limbs out of the way, we can see that the internal brace Fibertape sutures are going nicely down into that swivel lock suture anchor again, nice and compressed against the bone. And we have this beautiful low profile, metal free, all suture construct for this all inside ACL reconstruction.

All-Inside Quad ACL Reconstruction Using the FiberTag® TightRope® SB Implant With the InternalBrace™ Technique&nbsp;

At the Master Class in Shoulder Instability course, Albert Lin, MD (Pittsburgh, PA), reviews literature on the expanding indications and patient selection for the remplissage procedure, the concept of near-track lesions, and the utility of the Pittsburgh Instability Tool.

Anterior Glenohumeral Joint Instability: Literature Review on Remplissage and Hills-Sachs Management

OrthoPedia: Anterior Glenohumeral Joint Instability: Literature Review on Remplissage and Hills-Sachs Management

Obinna O. Adigweme, MD (Orlando, FL), shares how his transition to the iBalance® UKA system has improved efficiency and accuracy in performing partial knee replacements.

Transforming Your Practice: Benefits of the iBalance® UKA System

The eye balance has a lot of advantages. Number one, it's a gap balancing system. So you make your tibial cut and then you're never really chasing your tail because from there on you can bounce your flexion extension gaps independently. The accuracy is almost 100% whether you're using a lateral fixed bearing uni. You don't have to change it as opposed to a mobile bearing. With this system, it can cover the breadth of all patients and it increases accuracy and increases efficiency. I've never had a patient where I've had to go back revise. I've never had a failure in several years. The clinical outcomes have been phenomenal. Teaching and education, abundant, limitless resources, cadaver labs, everything that you need. Medical education at Arthrex is second to none. It could take someone who does only a few partial knee replacements a year to doing, like me, 15%, maybe up to 20% of their knee replacements as partial knees.

Transforming Your Practice: Benefits of the iBalance® UKA System

Carl T. Hasselman, MD (Bridgeport, WV), demonstrates a bunion correction using the Arthrex Lapidus I-beam plate, and highlights the benefits of the plate and associated instrumentation.

Lapidus I-Beam Surgical Technique

Lapidus I-Beam Surgical Technique

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