David R. Maldonado, MD (Houston, TX), reviews the evaluation and surgical management of gluteus medius tears as a common cause of greater trochanteric pain syndrome, with treatment selection based on tear size, tissue quality, symptoms, and associated intra-articular pathology.

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Treating Gluteus Medius Pathology

OrthoPedia: Treating Gluteus Medius Pathology

Patrick C. McCulloch, MD (Houston, TX), shares his experience with the Arthrex proximal humeral fracture solutions and how he decides treatment for patients along the continuum of care.

Arthroplasty Shoulder

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Dr. Patrick C. McCulloch Surgeon Testimonial: The Arthrex Proximal Humeral Fracture Systems Portfolio

Speaker  So if we have a younger patient who's involved in overhead sports, say they play tennis, then we may work hard to do an orif of approximately humerus fracture. If there are elements about that fracture pattern, poor bone quality, an older patient, a lower demand patient, then that's going to move towards a reverse shoulder arthroplasty with a more reliably good outcome. Stem geometry is important in reverse for fracture cases, having a rectangular one with smaller shoulders can help to get you some rotational stability. If you've got enough metaphyseal bone there and not having that too thick proximally so that you can actually do your tuberosity repairs is a nice feature of a reverse stem for fracture.

Dr. Patrick C. McCulloch Surgeon Testimonial: The Arthrex Proximal Humeral Fracture Systems Portfolio

Rachel M. Frank, MD (Denver, CO), demonstrates the Synergy Power™ system.

Imaging and Resection

Synergy Power™ System Product Demonstration

I'm Doctor Rachel Frank, a sports medicine and shoulder surgeon from the University of Colorado, and I would like to provide an overview of the Synergy Power system. This system was designed and developed in-house by Arthrex Product Development engineers, and is assembled at the manufacturing facility in South Carolina. I'm excited to walk you through the system and my favorite features of Synergy Power. The Synergy Power system is a medium and large bone system comprised of two handpieces, a dual trigger rotary drill, and a dedicated sagittal saw. These two handpieces are designed to cover a wide range of orthopedic applications, including sports arthroplasty and trauma procedures. Both Handpieces are ergonomic, lightweight, and durable, making them easy to use and comfortable for all hand sizes, even during long and complex cases. My favorite feature of the drill is the twist collet mechanism. This design is intuitive and allows for attachments to be quickly changed during a case. This feature saves time in the O.R., which increases our efficiency and creates a smoother experience not only for me as the surgeon, but also for the staff. Synergy power includes a comprehensive attachments portfolio for all drilling, reaming, sawing, and burring needs. The system will offer keyed and hybrid drill chucks and three different sized wire and pin drivers for optimal wire or pin retention. With the three different sizes clearly labeled S, M, and L, one features that you no longer have to adjust the attachment to accommodate your pin. So for example, here we have the medium attachment for the wire. Pin driver easily pops in and you can see that this tells you exactly what size that you're able to use in terms of your K wires. And for example, we'll place a two for k wire into the attachment. And that's all you need to do. And if I move around or the scrub nurse or scrub techs handing me the drill, I don't have to worry about the pin falling out, getting lost on the floor and having to scramble for another pin or another wire. We'll take the pin out when we're done and say we want to. Now put in a smaller pen, simply use the twist mechanism. And now we're going to use the smaller attachment. And we can see it's clearly labeled with an S. Easy to pop in. And we'll take a smaller wire in this case. And again as long as it's within the size that this particular attachment allows which is very clearly labeled, you no longer have to worry about where your pins or where your wires are going. And this makes it so much easier for both you and whoever's handing you the instruments. There are also two attachments micro, sagittal and reciprocating for making smaller cuts. Various other attachments along with several attachments, including a Hudson modified Trinkle reamer. The drill and ream functionalities are built into the attachments, so I don't have to switch between drill and ream modes during a case, and in general, I don't have to use as many handpieces when operating. Synergy power is all about providing greater ease of use, flexibility and ultimately cost savings. Now moving on to the sagittal saw. This handpiece is intended to be used for heavy duty cutting, and my favorite feature is the open hub design. No more blind insertion, as this design allows for easy visualization and confirmation of blade placement. As you can see here. Take the blade, push the button, insert it and done. Very easy. You can see exactly what you're looking at, and you don't have to guess that the blade is fixed. In addition, this ensures that the area has been properly cleaned after undergoing sterilization because you can see into every nook and cranny quite easily. The SOC features an indexing head that rotates every 45 degrees. Offering eight different cutting positions, and comes with a wide variety of large sagittal blades to meet all sawing needs and preferences. Next, let's discuss the Synergy Power battery packs and charger. The battery packs are sterilizable and offered in both a small and large size. Small for light duty procedures and large for heavy duty procedures. The charger has a simple user interface to easily determine the state of charge and offers fast charging. Charging a small battery pack in up to 30 minutes, and charging a large battery pack in about 120 minutes. One of the most unique features of Synergy Power is that this is a modular system with two handpieces. It has everything you need, but takes up so much less space than you're used to. That's better for your surgery center, better for speed, better for your entire team. This system is going to save money and be more efficient, which is going to make you as the surgeon and your team at the surgical center much more happy and ideally provide cost savings to the entire system. Finally, Synergy Power, of course, fits in nicely with Arthrex synergy family of products. Overall, Synergy Power is a powerful, versatile, and reliable powered instrument system, and I encourage you to experience synergy power as soon as possible.

Synergy Power™ System Product Demonstration

The Instability Express Instrument System is designed to house the latest instrumentation required for instability repair procedures in a single-level, low-profile, and customizable set. The light and compact case has a small footprint, making it ideal for ambulatory surgical centers (ASCs) with space concerns or larger hospitals with high case volumes.

Shoulder

Arthrex Instability Express Instrument System

Arthrex Instability Express Instrument System

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

Foot and Ankle

Arthrex Beaming System: Cadaveric Surgical Demonstration

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

Arthrex Beaming System: Cadaveric Surgical Demonstration

The Nano FiberTak® anchor is the smallest anchor in the Arthrex portfolio. The Nano FiberTak anchor is single-loaded with 0.6 mm SutureTape for less tissue pull-through and a flatter knot stack than traditional round suture constructs. The 1.0 mm × 10 mm drill hole makes this anchor ideal for hand and wrist surgery.

Hand and Wrist

Nano FiberTak® Soft Anchor: The Smallest Arthrex Suture Anchor

Speaker  The Nano FiberTak anchor drill is one millimetres and is drilled to a depth of ten millimetres. The first eight millimetres of the drill bit is one millimetre in diameter, while the last two millimetres is 1.1mm in diameter. Advance the drill to the ten millimetres depth. Stop. Verify depth and position with fluoroscopy. Advance the anchor by hand until the clear plastic retaining sleeve contacts the backstop, which indicates the anchor is fully seated. If hard bone is encountered, use a light controlled mallet. Tap disengage the black suture release tab, remove the needle holder and unwind the sutures to disengage the inserter from the FiberTak anchor. Remove the blue retention suture tension each SutureTape strand back and forth to draw the suture loop beneath the cortex and set the anchor. Perform the desired repair with the 0.6mm SutureTape.

Nano FiberTak® Soft Anchor: The Smallest Arthrex Suture Anchor

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.

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

At the On-Call With Arthrex Trauma course, Jack W. Weick, MD (Columbus, OH), discusses case examples to highlight ﬁxation approaches in olecranon and proximal ulna fractures.

Trauma Upper Extremities

Fixation Options in Olecranon and Proximal Ulna Fractures

OrthoPedia: Fixation Options in Olecranon and Proximal Ulna Fractures

J. Lee Pace, MD (Plano, TX), explains the value of Nano arthroscopy for pediatric applications.

The Benefits of Nano Arthroscopy for Pediatric Orthopedics

Nano arthroscopy makes a small case even less invasive. It is a smaller camera. It has smaller instrumentation. It allows you to navigate into places easily that were once hard. With kids, sometimes anxiety and concern about post-operative pain and recovery can sometimes dominate their psyche. So when I'm speaking to the parents of a patient regarding using nano arthroscopy on their child, I want to highlight to them the lesser amount of fluid distention in the knee causes less quadricep atrophy and therefore less pain. It makes that whole recovery process easier as well. So when you explain that to parents, it's very attractive right now. We have great instruments, great resolution. We have this enhanced sterility. And now a single use product that I think is going to be very advantageous and attractive in taking care of this younger patient population. The most common cases that I'm using the nano arthroscopy platform in kids are going to be meniscus repair to include discoid meniscus, osteochondritis, dissecans, and also complex procedures like meniscus transplantation. When I'm speaking to a surgeon who's interested but hesitant to make the switch to nano arthroscopy in the pediatric population, I simply tell them, just give it a shot on a very basic diagnostic arthroscopy. Just get it in your hands on a patient in a very low risk scenario, and see for yourself how you like it. Navigate those smaller joints, cause less to no iatrogenic injury. Perform more precise tissue resection manipulation repair for the pediatric population, nano arthroscopy has the ability to become the standard of care.

The Benefits of Nano Arthroscopy for Pediatric Orthopedics

Patrick J. Denard, MD (Medford, OR), presents findings from a retrospective study evaluating predictors of subscapularis tendon healing following repair. Reviewing data from 279 patients, Dr. Denard introduces a scoring index that identifies key risk factors—including fatty infiltration of the lower subscapularis and supraspinatus muscles, BMI, and sex—to estimate the likelihood of tendon healing. The model provides a practical tool for surgeons to assess risk preoperatively and determine if augmentation or alternative procedures may be warranted.
<a href="https://www.arthrex.com/resources/VID1-007954-en-US/subscapularis-tears-presentation-series-part-1-recognition?objectID=human.resource.en.1408c35c-14c4-4e38-bd2c-52b4527fe5e6.1&amp;queryID=c8a8fd6a7aad425f4c7a7ddea15222ab">View Part 1: Recognition</a>
<a href="https://www.arthrex.com/resources/VID1-008215-en-US/subscapularis-tears-presentation-series-part-2-outcomes?objectID=human.resource.en.a6bc0eea-e870-43e1-b1a6-d5cab3cbad57.1&amp;queryID=27bd2007639c4606bae174e3be14f168">View Part 2: Outcomes</a>

Subscapularis Tears Presentation Series (Part 3): Predictive Healing Index

Speaker  I'm Patrick Denard from Medford, Oregon. I want to share with you a recent study we published on predicting healing of Subscapularis teres. Now, much like we know, the ROI is a tool for us to predict healing of supraspinatus and infraspinatus teres. We've developed a scoring index that helps you predict whether or not the subscapularis will heal. This is a retrospective study of my patients over a several year period. We had 279 patients that had post-operative ultrasounds that we could use to assess healing, at a minimum follow up of two years. Now, overall failure rate of subscapularis teres is very low. As you can see, healing is about 89%. This is a look at our cohort, our baseline demographics. Here you can see we had a wide variety of tears. But also what's notable is we had several patients with advanced fatty infiltration and also those that had associated fatty infiltration of the supraspinatus. And this allowed us to look at several variables to create a prediction model for healing of the subscapularis. Here you can see in our regression analysis the factors that stood out the most for healing BMI was a factor. Female sex was a factor. But what I really want to highlight is the biggest factors are as if you have fatty infiltration of the lower part of the Subscapularis, or if you have associated fatty infiltration of the supraspinatus that plays a big role in whether or not you'll get subscapularis healing. Speaker  We could then take these and develop a scoring system or points per variable to help predict Subscapularis healing. Our prediction model was very accurate, and you can see we had a division of healing based on points. If you have less than four points, your chance of getting subscapularis healing is very, very high. It's over 95%. As you get to 5 to 8 points, that drops down to about a 20% chance of failure or 80% chance of healing. But as you get over nine points, you have about a 55% chance of failure. Now, how do you apply this? I think what I want to do here is show you some examples. So if you have an isolated subscapularis tear Lafosse type three meaning greater than 50%, you have three points. If you have stage two fatty infiltration of the lower part of the muscle belly of the subscapularis, that adds four points. So you're going to be right in that mid range. This particularly increases when you have combined tears. So here we see if we have associated fatty infiltration of the supraspinatus. Speaker  We have additional points. And if we add points on for BMI and female sex That, of course, is going to go up any further. So what I take this to mean is that if you have fatty infiltration as well of the supraspinatus, this is going to lower my threshold for augmentation of the subscapularis in particular. That's based on the fact that subscapularis healing is critical for function, as I've discussed previously. So the take homes here are that subscapularis healing is really much higher than supraspinatus and infraspinatus repairs. So remember about 90% of Subscapularis tears are going to heal. Now you can preoperatively predict subscapularis healing. So what I take this to mean is that you can use this type of scoring index to consider augmentation in about 10% of the cases and or in some cases, even reverse shoulder arthroplasty. It's really important to know that large tears with fatty infiltration of the lower part of the muscle belly, as well as those with associated fatty infiltration of the supraspinatus, are those that really have the highest risk for failure of healing. And that's where you're going to see about that 10% that you're going to consider other things than a standard repair, such as augmentation. Thank you.

Subscapularis Tears Presentation Series (Part 3): Predictive Healing Index

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

Knee

iBalance® HTO Using Patient-Specific Osteotomy Instrumentation

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

iBalance® HTO Using Patient-Specific Osteotomy Instrumentation

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

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

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