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Anand Vora, MD (Chicago, IL), presents a detailed overview of clinical evidence supporting evolving treatment techniques for insertional Achilles tendinopathy.

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Insertional Achilles Tendinopathies: Literature Review on Evolving Insertional Achilles Treatment

OrthoPedia: Insertional Achilles Tendinopathies: Literature Review on Evolving Insertional Achilles Treatment

Raymond J. Gardocki, MD (Nashville, TN), provides an in-depth overview of the anatomical orientation through an endoscope lens during an endoscopic transforaminal approach for discectomy.

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Voyage Into Kambin’s Prism

Welcome everyone. I'm Doctor Ray Gardocki, an orthopedic spine surgeon from Nashville, Tennessee, specializing in minimally invasive and endoscopic spine surgery. Today, I'm excited to take a deep dive into understanding the anatomical orientation through the lens of an endoscope. During a transforaminal approach, we'll explore Kambin's prism at L4 five and the surrounding anatomical structures. Just as technology has revolutionized how we navigate our world, it's also revolutionizing the way we understand anatomy. Now, a traditional surgeon performing open procedures can use all the exposed landmarks to identify their location. Imagine using a map to navigate a city. If you don't know where you are, you start with a wide overview of the entire city. Then zoom in to your specific focal point. You can look at cross streets and surrounding buildings to pinpoint a specific intersection. This broad perspective represents how traditional open surgery allows surgeons to see and navigate using a wide field of vision. In contrast, endoscopic surgery requires a different approach in perspective. Think of it as navigating the same city with a map that's permanently zoomed in. In this example, the endoscopic surgeon only has a view of a small section of the curb and needs to understand where they are and what surrounds them using this zoomed in view. During this step, I am looking for a landing spot or home through lateral and AP fluoroscopic imaging. One of the major difficulties surgeons have when transitioning to transfemoral endoscopic surgery from open midline surgery is orientation. Surgeons understand the anatomy of the spine. They know the relationships between the pedicle, the traversing nerve root, the exiting nerve root, the disc space, and the superior articular process. They're just accustomed to looking at those structures from a posterior midline approach. As soon as they look at these structures through a transforaminal approach, they become disoriented. The best way I can convey this concept is with the aid of this visual. Now, when you look at this image, it makes no sense. Why is there a floating rock above a cliff in the background? But once you change the image to a familiar perspective, it all makes sense. The transforaminal approach is much like the orientation of this image. The anatomy doesn't change, just the perspective. The traversing route is still medial to the medial wall of the pedicle. The disc is still above the pedicle. The exiting route is still below the cranial pedicle, and the superior articular process still extends out from the top of the pedicle, forming an arch in the foramen. The anatomy and the relationships don't change, only the perspective. Once you become accustomed to this perspective, everything becomes familiar again. So let's take a journey into Kambin's prism, as seen through an endoscopic approach to l45. We're all familiar with Kambin's triangle. It's defined by the exiting root, the traversing root, and the endplate of the caudal vertebral body. This outlines the floor of the triangular working zone. However, this region is better described as a three dimensional space or prism that changes as we change the level we're working. There tends to be significant overhang from the lateral aspect of the superior articular process at L4 five and L5 S1, enough so that bone removal of the sap is commonly required to access the lateral recess at these two levels. Bone removal is rarely needed above L4 when there is no underlying foraminal stenosis. This is the L5 L5 superior articular process, little strip of the L5 vertebral body and endplate. This is the sap in Wagner's arch. Here is the disc. The floor of the foramen and the entry into the canal. The traversing nerve root is in here and the exiting root is up there. When performing transforaminal spine surgery, it's crucial to ensure that there's enough room for both the instruments and the dorsal root ganglion in the foramen. Too much pressure on the DRG can cause discomfort and potentially lead to radiculitis. This is why I prefer my neuromonitoring for Transforaminal approach to be an awake patient. If you put excessive pressure on the DRG, the patient will respond. Additionally, when dealing with Cranially migrated fragments, we need a slightly different technique, as working more cranially in the foramen increases the risk to the DRG of compression. Now, once you find the pedicle, you know where everything else is. The pedicle is the lighthouse of the spine. From here the arch superior articular process and disc are easily recognizable. This is your home. If you're ever feeling lost, just return to home as a quick pearl. If you did your approach without making a large fascial defect, the soft tissue and bony foramen will hold the scope docked in the frame in the home location. Now that you understand how to visualize kambin's prism through an endoscopic transforaminal approach at L4 five, let's discuss different disc pathologies. Here is a typical contained posterolateral herniation that displaces the traversing root dorsally. Looking up at this herniation from the floor of the foramen allows you to Allows you to visualize the lateral side of the herniation protruding up from the disc space to the sap. This is a good beginner case. You will enter the base of the herniation laterally and remove disc material from under the annulus. This will continue until the traversing root drops down to the field of view, pulsates to heartbeat and is freely mobile. Here is an intraforaminal herniation within the foramen with proper targeting. The scope will end directly upon the herniation, making this another good beginner case. If the herniation is cranially extruded and dorsally displacing the DRG on the existing root, you must visualize the bony floor of the foramen, which is the back of the cranial vertebral body underneath the DRG and exiting root. Far lateral herniations are more technically challenging because you need to turn the scope around 180 degrees, and there is no bony architecture to hold the cannula and endoscope in place. This means that you need to control both the depth and rotation of the cannula, the endoscope and the instrument all at the same time. The DRG often needs to be retracted to expose the herniation, which induces a 20% risk of radiculitis between the root retraction and the reperfusion of the DRG. You must visualize the bony floor of the foramen, which is the back of the cranial vertebral body underneath the DRG and exiting root to ensure an adequate decompression. The endoscopic approach offers easy and direct access to most pathologies through an eight millimetres incision, minimizing disruption to the muscles and other soft tissues. This technique results in reduced blood loss, less muscle disruption, faster healing, and allows for a quicker return to work and normal activities. And there's no need for postoperative narcotics. Now that you have a comprehensive understanding of visualizing Camden's prism through an endoscopic transforaminal approach at L4 five, as well as the anatomic nuances and techniques for different herniation locations, you're better equipped to enhance your surgical precision and patient outcomes. Thank you.

Voyage Into Kambin’s Prism

The MaxForce™ MTP fusion system features a unique gear mechanism along the plate, allowing for controlled, dialed-in compression across the joint. Featuring 18 different plate options of varying sizes and curvatures for primary and revision cases and multiple Arthrex plating-screw and cross-screw options to best address patient needs and anatomy, the MaxForce MTP fusion system provides a comprehensive solution for 1st MTP arthrodesis.

MaxForce™ MTP Plating System Features and Benefits Animation

MaxForce™ MTP Plating System Features and Benefits Animation

This animation demonstrates the dual-view capabilities of the Synergy Vision™ imaging system using the Pano™ scope and NanoNeedle™ scope 2.0 in the shoulder, knee, and hip.

Dual-View Applications Using the Synergy Vision™ Imaging System

Dual-View Applications Using the Synergy Vision™ Imaging System

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;

Peter C. Yeh, MD (Stoneham, MA), shares a surgical pearl for using a weighted clamp to optimize graft passage during all-inside ACL reconstruction.

SpeedPearl: All-Inside ACL Reconstruction Using a Weighted Clamp

All-inside ACL reconstructions require a level of precision and preparation, as proper graft and suture management are keys to ensuring a smooth case. Here's a simple but very effective way to pass the graft into the femoral socket. Rather than having an assistant's hand pulling on the tibial shuttle loops, I use two clamps to weigh down the tibial shuttle loop suture that comes out of the Am portal and tibial incision, taking advantage of gravity to tension it down and out of the way. The heavier the clamps, the better. This allows for ease of graft passage, but more importantly also frees up an assistant's hand to do something else to further the case. One clamps both sides of the tibial shuttle, stitch both the Am portal side as well as the tibial incision side. For extra weight, I put an additional clamp on just the suture loop coming into the Am portal to make it even heavier. This allows tension on the suture and allows for the passage of the graft without worry that the tibial shuttle sutures will get pulled in.

SpeedPearl: All-Inside ACL Reconstruction Using a Weighted Clamp

John G. Kennedy, MD (New York, NY), discusses diagnostic and treatment applications using the NanoNeedle™ scope 2.0 for ankle arthroscopy conditions such as anteromedial and anterolateral ankle impingement.

Revolutionizing Ankle Arthroscopy Using the NanoNeedle™ Scope 2.0

Hi, my name is Doctor John Kennedy. I'm an orthopedic professor at NYU Langone in New York. We're going to be talking today and showing the new 2.0 nano needle, and we're going to be looking at it specifically in the ankle joint at the anteromedial impingement and anterolateral impingement. And today we're going to be going how do we diagnose this. And also how do we fix it. And so with no further ado we'll carry on. So we're going to be talking this morning about anterior arthroscopy using a nano needle. And the new 2.0 nano needle. And the first thing we're going to be talking about is how do we set this up. So this is a procedure that you can do in the office. Or indeed you can do it in the operating room. And the way that we do it is exactly the same. We start off always with identifying the superficial peroneal nerve. And you can see that running on the lateral side here, that is the structure that is most at risk. So we always identify that with the third toe for toe flexion sign. And that then makes that more prominent. Our portal will be slightly lateral standard entry lateral portal to that. And then we'll have a medial portal as well. And both of these will be a working portal and a visualization portal. So in the office, once the patient is settled in then we identify these. And the first thing that we do is we give them a local anesthetic with marcaine a lidocaine 1 to 1 ratio. And we inject that into the joint. And we can see here and typically we'll give about 4 or 5 cc's into the medial aspect. And then we come over onto the lateral aspect again always recognizing where that SPN is. And then we inject into the lateral aspect of the joint as well. After that then we leave the patient for about 5 or 10 minutes while we get everything set up. And I think it's important at this point to underscore that in-office needle arthroscopy is truly a team sport. This is not just all about the surgeon and patient. We have our nurse or nurse assistant with us who's versed and skilled in this, and also our local rep. I think that is critical for this because when a patient is awake, they will recognize and certainly see if people are not familiar with what's going on. So I think it's critical that everybody is on the same team. Everybody plays a different position, but collectively we play to win. So that's the setup for anterior arthroscopy using the new needle scope. So for the next portion of this, what we're going to do now is make standard portals on the Andromeda and Anterolateral aspect of the joint. And again we use an 11 blade. And we just simply go through the skin. We don't have to go through the entire length of the blade, just about a 2 to 3 millimeter incision. And because in the end, of course, we're not going to be using sutures and it's just steri-strips. So we go through this into the capsule, gently remove that, and then we have our trocar, which is slightly beveled. Again you want to protect the underlying structures. Put your finger just at the about a centimeter or two from the tip and then advance in. And we're into the joint and you can feel that pop and you have to represent you We have to let the patient know that they will feel a pop. They should feel no pain whatsoever. There's the capsules are completely anesthetized, as is the as is the joint. So they'll feel that mechanical pop and hear it, but they won't feel anything in terms of pain. Then we remove this and then we put in our new 2.0 needle. And you'll see, once we get into the joint, you can see automatically how really clear this is on the top portion of the horizon. There you're seeing the tibia and this is the talus. And if we advance now towards the lateral side you can really see the depth and clarity. And of course that all comes from the the new 720 by 720 sensor that we have, which is an order of magnitude better than what we've been using before. And you can really see how clear this is as we're looking over in the lateral side. Because this as we move over to the lateral side then you can trans illuminate. You can see some of the AI TfL you can see some chondral damage there. The next portion of this we're going to use the needle. And the needle will then identify our lateral portal. So again we've predetermined where that's going to be. And you can see and we just take a picture of that. And of course all the time you're talking to the patient because the patient at this point wants to know. And just for the purposes of this demonstration, we're going to say this patient had a recurrent ankle sprains and this ligament here. The atfl or Bassett's ligament is hypertrophic, and that can often cause snapping and damage the cartilage, as indeed it has done here. So once we've put the needle in, then we would throw the needle. We use our 11 blade once again. And we just make that small incision through there. This is a 3.5 shaver. We use a three and a 3.5. This is a receptor. And you can see we've come through that lateral portal. And this will have the ability to shave everything from the lateral side, right across the joint, right over to the medial side. And at one point when we need to look at the medial side, we'll just simply change portals. One thing to note here on the when you're looking outside the joint is how we hold the actual needle scope. It's important that you stabilize that against the body, and that reduces any emotion or aberrant motion that you might get from if you were choked up here. Any sort of you can certainly get some tremor in your hand if you're up here. But if you're stabilizing against the joint, that tremor is eliminated or reduced. So here we are. We're in the joint, as I said, for the sake of demonstration, we're saying that this is a hypertrophic atfl or an anterior ligament of the of the ankle joint. And this is commonly syncretized or scarred after a recurrent ankle. Sprains. The atfl is underneath here we can dive down here and we can see the atfl will be underneath there, but the atfl is the one that becomes hypertrophic. So we can use the shaver and we can start shaving away on that. And we take you can actually take the entire this ligament away without compromising ankle instability or ankle stability. And, but we're just taking the anterior two thirds of this fascicle away. And you can see the damage that it's done to the control surface here. And I'm just going to introduce, actually to show you that I'm going to use you. This nice new probe that we have is graphite covered. So it reduces glare. And it again the profile of this fits through our portal is very nicely. So again there's going that is going to be the remnant of our TfL or Bassett's ligament underneath here we can dive down and we can see down there is the Atfl and we don't want to touch that on this particular model. And so we're just resecting that. And you can see as the talus snaps over that hypertrophic edge, it can cause damage to the Taylor control surface, and you can see the wear that's occurred here over time. And of course, that will create a lateral osteochondral lesion at some point if that's not addressed. So that's really the lateral aspect. You want to make sure when you're dealing with anterolateral impingement that you always dorsiflex. And you can see now that there's really no impingement there. And there's a nice gliding motion. But if there was impingement and I'll take the shaver again, you can use the shaver, but oftentimes we'll use a bur. So we'll just as we're waiting for the bur to be loaded, we'll just show you in terms of the shaver, we can just shave away some of that bone and we'll just pour it instead of oscillate. We'll just put it on forward to shave away. Again, remember that this is an in-office procedure. You just have to warn the patient. Although they will have no pain at this point, that they will feel the vibratory sense within their joint and not to be alarmed with that. But again, you can see we're getting nice reception if this is a large exostosis or osteophyte, and we'll change that to a three or a four bur, which we'll do now again for the purpose of demonstration. And again, you can see how really critical it is to have your assistant just well versed in knowing what the next steps are going to be. And I think that is, as I was saying earlier, is so important in terms of a team sport. This really is a true team sport, particularly when the patient is awake and is aware of everything that's going on. It has to look like a seamless transition from player to player. And that's particularly so because at some point we need to wash out the joint or lavage the joint. And our company representative will be there and knowing when that occurs so that they're ready on standby. They don't have to struggle to find the the pump. So they're ready to do that or ready to take a picture. Because there are times when you're holding the camera that it is difficult for the operator to address or to take a picture. They'll lose that picture. So the nursing assistant or the rep will take the picture for you. So that's really a demonstration of the anterolateral impingement. So we've taken soft tissue away and we've taken bone away. And of course if that's all we do we can leave half of it undone. It's more common on the medial side, but oftentimes on the lateral side down here, just as you're getting into the neck of the talus, they may have an exostosis here and you don't want to miss that. So always make sure you dorsiflex that joint all the way to make sure that there is nothing there that's going to cause any impingement. So on this model we can see that that's a really nice gliding moment motion. The atfl or that hypertrophic Bassett's ligament is gone largely. We can take a little bit more away if we need to. So again, we can now move our camera over to the medial side to look at anteromedial impingement. So we're introducing now our new 2.0 beta. This is more robust than the previous one. And you can see it's got a really nice cutting profile to it. And again we're simply resecting that anterolateral impingement. So we're able to cut that away. And sometimes you just need to do that to create a surface that the shaver can grip on a little easier. But you can see how nice is a really good tactile feedback on this. You can hear and feel those clicks. And again, it's always useful when a patient is looking at this. It looks like this is an industrial instrument. So it's much better to show the patient that this is really quite tiny. This is the profile. And this is just two two millimeters. So it's very, very small of course. Enormously magnified for the patient to see. So you can see we've taken that away. And then we'll just put our shaver in again after that to clean that up and make that as smooth edge.

Revolutionizing Ankle Arthroscopy Using the NanoNeedle™ Scope 2.0

At the Orthopedic Technology and Innovation Forum (OTIF), John D. Adams, MD (Greenville, SC), reviews the latest literature highlighting trends in the surgical management of intertrochanteric fractures and the associated clinical outcomes.

Intertrochanteric Fractures: Literature Review on the Management of Intertrochanteric Fractures

OrthoPedia: Intertrochanteric Fractures: Literature Review on the Management of Intertrochanteric Fractures

Marc W. Gerdisch, MD (Indianapolis, IN), demonstrates his preferred thoracotomy closure technique with FiberTape® sternal closure using a dual-tensioner approach. He highlights the advantages of FiberTape Cerclage, noting its broad footprint helps reduce the risk of bone cut-through compared to traditional suture, while the enhanced closure method minimizes the potential for lung herniation

FiberTape® Sternal Closure for Rib Approximation After Thoracotomy Incisions

I'm Mark Curtis. I'm chief of cardiothoracic surgery at Franciscan Health in Indianapolis. We're going to show you our method for using the fiber tapes for Rib approximation in any size thoracic incision. So for anyone who does thoracotomy surgery, whether that be lung surgery or minimally invasive valve surgery, no matter what size incision you make, if you make an incision in the intercostal space and you spread the ribs even a little bit, you are then vulnerable to lung herniation. So for folks who have been doing thoracotomy surgery of any variety for a long time, they've encountered a lung herniation at some point. So what we've been doing now is using the fiber tapes for our rib approximation for any thoracotomy. We do that as a figure of eight. We use the blunt tip needle, and we always start at the middle and work our way out. So in this case I'm going to use two figure of eights. And the first one will go here below this rib. And then the second is going to go a little bit farther medial. And we can really travel. We can cover the whole space of the incision. So one of the things that you'll notice of course, about the fiber tapes is they're considerably wider than the heavy suture that we would typically use. And that gives us a couple of things. It gives us the power to approximate those ribs as much as we choose. We don't want it too tight, but we want to bring them together. And then also because they're wider, they're much less likely to cut through the rib when you tighten them down. So we have the ability to be a little bit more vigorous with the tension on the closure than we would with suture, because it won't cut through or it's less likely to cut through. And also you're going to see that it's a titratable amount of tension so that we can really decide just how tight we want it and how close we want the ribs when we finish. So now we're finishing our figure of eight. We're going to come around. We started in the middle, worked our way out medially and again. This could be for any size incision. Then our final bite takes us back laterally to where we started. So take another tape and then again starting toward the center of the incision. We'll pack our first pass. Next bite is going to go way lateral out toward the end of the incision. Another lateral bite. And then we're going to finish in the middle again. So now we've got our fiber tapes in position. And we're going to go ahead and start to pass them through. So we can take all our retractors out. So we've passed the tail of the fiber tape through the little cinch knot that's built into it. And Then if we just want to take some of the slack out, we pull up on the one that's farther medial, the farther past that we did earlier of the same suture we pull up on that, we go back and forth a little bit and we get them close together. And again, same thing. Pull up here a little bit. We'll grab this side. We're work that down a little bit now. So now you can decide how you want to approximate this. We can do this by hand just by doing this. And the ribs have come together quite a bit already. So again here push that down. Pull this back so it can be done most of the time completely to close that way if you want to. But you can also go ahead and use the Titratable tensioner so that you can set the amount of tension that you're going to have on the sutures as you approximate the ribs. And I think this is the ideal way to do it, really, because it is more powerful if you tighten it all the way. So you have to be cautious Yeah, but it also is something you can do in small changes. So I tighten this a little bit. So the tensioner allows us to kind of titrate the amount of force that we're putting on there. We can feel the space between the ribs. We don't want the ribs right together because we don't want them to rub against each other. That can actually cause pain for the patient. And then you can have your assistant hold this one and then take the second tensioner. The fibertape is passed up from the tip of the tensioner. We aren't separating the tapes. There are two strands. The two strands go all the way up through the wheelhouse here. And then as I turn the handle, the wheelhouse turns and it closes the space. So now I can feel in there. I've got just about a finger breadth of separation there, and we're going to stop there. So and the different surgeons will want this, you know, different approximated differently with greater tension. But this is fine for us. We've got it nicely closed there, and then we release the tensioner and then we cut these strands. And we tie on top of our slipknot. So there's a slipknot that's built into it that's already there, that holds. So it's not moving. And then just in order to secure it, I'll put three knots on top of that and then we'll cut this one. So here I can feel and I have my gap here that I think is reasonable, which is just barely maybe the height of my, my index finger. And so the ribs aren't rubbing together, but there's also not a gap there that would pose a problem later. We put three knots on top of that and we cut both of those. And then that's our closure for the inner space.

FiberTape® Sternal Closure for Rib Approximation After Thoracotomy Incisions

E. Lyle Cain Jr, MD (Birmingham, AL), demonstrates surgical steps, during a live surgical case, using tensionable Knotless FiberTak® soft anchors to repair a posterior glenohumeral labral tear. Dr. Cain describes the technique using the Rotation Lasso suture passer to create simple and mattress repair stitches. The final repair shows an anatomic, low-profile knotless repair.

Re-Live Surgical Technique: Posterior Labral Tear Repair With Tensionable Knotless 1.8 FiberTak® Soft Anchors

This case represents a posterior labral repair in the left shoulder. The patient had tried conservative treatment with rehab, was diagnosed with a posterolateral tear by MRI. This procedure was a posterior labor repair arthroscopically using 1.8 Nautilus FiberTak anchors. The arthroscope is in the anterior portal, viewing posteriorly. You can see a spinal needle that's been placed for an accessory posterior portal that will be used for anchor placement, as well as suture passage. The FiberTak drill guide has been placed through the accessory portal. As you can see, there's a black line which indicates the maximum concavity of the drill guide. And this drill guide can be turned in order to allow aiming towards the center of the glenoid, which is critical for the best bone purchase for these anchors. We then elevate the hand and push down against the deltoid to get a nice vertical passage of the drill into the inferior glenoid bone. This prevents skiving off the inferior bone. I like to cycle this drill in and out a couple of times to clear the bone debris. We then use hand pressure to apply the anchor into place. And it's impacted with the back of our hand until it's fully seated. The centering sleeve keeps you from being off center and allows excellent placement of the anchor. Once the anchor is applied, we use a rotation lasso to pass the anchor suture and the repair suture through the labrum. As you can see, the rotation lasso allows you to move the lasso and rotate it perpendicular to glenoid face. We'll try to go a little bit inferior to do a little bit of a superior capsular shift. So we'll grab about a centimeter of capsule and labrum, come out on the glenoid bone junction and then pass the rotation lasso into the shoulder. We then spin the lasso to make it perpendicular to allow easier passage. And we reach through our straight posterior portal with a loop grasper to grab the sutures and do an all-inside shuttling of the repair stitch. In most cases, I like to do a mattress suture on the lowest part of the labral tear. I think this gives you better labral biomechanics, as shown by millet and others, and also brings the labrum up against the neck of the glenoid, where healing should be better. Repair stitch is pulled through the SutureLasso, then the lasso is converted to pull the repair stitch through the labrum and capsule. At this point, we want to convert the anchor. I'll grab the repair stitch and the round conversion stitch, which has a loop through the accessory portal, will then load the repair stitch to the purple mark in the loop, which gives you proper length for passage. And then we pull the opposite end of the suture passage stitch until the anchor is converted and the repair stitch goes through the soft anchor. At this point, I'll cycle the repair stitch. Several times I'll pull it down tense until we get a good approximation. I'll leave this repair stitch intact so I can tension even further after I get the second anchor. In the second anchor is in place with the drill guide again in the accessory portal. The turn of the curve posterior at this point. So I'm more vertical into the bone and have a better angle, and the drill is cycled several times in and out to get the bone debris out of the tunnel. The anchor is then placed by hand, centered using the centering sleeve, and then impacted by hand into the bone to set the anchor in place. This repair stitches then shuttled through the labrum out the capsular attachment and is ready for conversion of the anchor. The anchor is converted through the anchor placement portal, which is the posterior accessory portal, and then as this anchor is tensioned, I like to grab through the posterior cannula, the labrum, and advance it so that I get a nice good tension in the labrum. I will then grab the original mattress suture again and tension it one last time before I cut the sutures. We then sequentially apply up the posterior glenoid. Simple sutures using the knotless device. And for most cases, on the opposite side of the shoulder, this time being the anterior portion of the shoulder. I'll put a simple anchor in order to act as a ripstop anti propagation stitch, and also tension the anterior band of the inferior gluteal ligament. If this were an anterior labrum, I would typically put another anchor on the posterior inferior portion. Again, tensioning the axillary pouch, the hammock effect, and promoting a ripstop effect to keep the labrum from propagating the opposite direction.

Re-Live Surgical Technique: Posterior Labral Tear Repair With Tensionable Knotless 1.8 FiberTak® Soft Anchors

The Arthrex ultra-minimally invasive endoscopic spine portfolio is a comprehensive solution that includes enhanced visualization with the Synergy camera system and operative endoscope, ergonomic WishBone™ and ring-handled instrument options, a steerable electrosurgery probe, and an endoscopic instrumentation system.

Arthrex Ultra-Minimally Invasive Spine Portfolio Overview

Arthrex Ultra-Minimally Invasive Spine Portfolio Overview

Tim R. Lenters, MD (Grand Rapids, MI), highlights the latest metal segmentation feature in the Virtual Implant Positioning™ system while planning a challenging glenoid revision with significant bone loss using the Augmented Modular Glenoid System.

VIP Vision™: Episode 11—Metal Segmentation for Revision Planning

Hi, my name is Tim. I'm a shoulder surgeon in Grand Rapids, Michigan. I've been using the VIP system now for over ten years, and I'm happy to share a case presentation that highlights some new features of the planning software. The planners can now perform metal segmentation on your surgical plans for use in revision cases of existing implants. So what previously used to require potentially several surgeries, with the first surgery being removal of an existing implant to allow us to obtain a clean CT scan, that first step is no longer needed with metal segmentation features of the VIP system. I'd like to use this case to highlight some of those features on the platform. My patient is a 68 year old. She's fairly low demand female. She had a reverse total shoulder arthroplasty five years prior to her presentation with me. She describes one month of progressively worsening pain in her shoulder, and she has also had a few falls over the last year, although none of these falls led to a significant worsening of either pain or function of her shoulder. I was able to find her x rays from her early postoperative period. She has a reverse total shoulder arthroplasty with a lateralized glenoid sphere. It seems to be an appropriate position in terms of the RSA angle, as well as in relation to the inferior scapular neck or x rays. On presentation to me, show a catastrophic failure of the base plate with fracture of all three of the fixation screws, and in my mind, I felt it was essential to rule out the possibility of an indolent infection, despite her history of some falling onto the shoulder. I did do an infection workup. Her inflammatory markers were normal, including the SED rate, the CRP, and her white count. I also aspirated the shoulder to culture and the cultures did not grow. Any organisms at three weeks or vitamin D level was also checked and found to be in the low range of normal. The CT scan was also obtained and I found it somewhat challenging to observe what sort of bone was remaining into the glenoid vault on this axial cut. I can just appreciate that there's bone loss and maybe some residual bone inferiorly. The coronal image shows a fairly large defect here, and raise some concerns about my ability to utilize a standard implants for this reconstruction. I did decide to upload this image to VIP software to see if potentially, I'd be able to utilize a standard implant for this reconstruction. So at this point, I uploaded the study to VIP, and we'll go through sort of a live planning session to demonstrate the features of the system. You can see the old existing implant is green. You can see the existing screws in the vault. The planners have been able to identify those structures and highlight them with these blue outlines. The surgeon can easily toggle visualization of these features with this little window on the right side, and this will make the implant disappear. And what you see then is what's left of the scapula. And it's fairly obvious that there's a very large posterior defect in this glenoid vault, sort of an uncontained wall defect. The vault is missing. You can see there's maybe a little bit of bone remaining in the base of the coracoid process. There's a nice column of bone anteriorly and maybe some bone inferiorly. You also can see that perhaps the scapular spine is available to use asphyxiation. So in my mind at this point I had really three options. One option would be to utilize the scapular line for fixation, to try to sink the post of the base plate down the spine of the scapula. Second option in my mind was to use Grammont principles and Medialize. And inferiorly lies the sphere to try to minimize the shear along the back side of the implant. And then my third option would be to develop and manufacture some sort of a custom implant, which is my which would be my least preferred option. So my first option was to look at use of the alternate scapular plane. And if we bring that implant in, what I thought was the alternate scapular line here you can see the post is seated in the base of the scapular spine. The windows on the left side here can show you what sort of bone is available on either side of your central post, and there seemed to be a nice quarter of bone in this position. The top window gives you sort of a coronal view, and here you can start to appreciate where the glenoid might reside in relation to the inferior scapular. And I did have some concerns with the position of this implant. I was worried about this bone posterior inferiorly that the humeral cup might impinge on that bone. And so this looks like it might be an option in terms of fixation of the center post. I did have some concerns about the overall position of the glenoid in relation to this inferior glenoid neck. So I looked at another option, which would be more of a Grammont principle to digitalize and medialize the sphere. And you can see in this position, if I remove the sphere itself, the base plate seems to be seated reasonably well. I have 53% backside contact with just a non-augmented base plate. The post seems to be seated in a nice area of residual bone, both on the axial plane as well as on the coronal plane. The sphere looks to be in a better position in relation to that posterior inferior scapular neck. And so in my mind, this seemed like a very reasonable option. I did want to utilize some other features on VIP. So if we look at the range of motion module, we can see that in this position there may be some issues with impingement of the humeral cup against some remaining bone around this sphere. And so it would be useful, I think, at this point, to utilize the Osteophyte removal tool to remove some of that bone and see if we can improve the range of motion. You can use that tool from this window. So I'll go through some of those steps right now. Remove some of these potential sources of impingement. We can reassess the range of motion following this bone removal. And this is something I would do in surgery if I see sources of impingement. I'll just simply take a roger and remove some of these problem areas. But once we do that, we can reassess now the range of motion we'll bring in the humeral component one more time. There's a nice abduction. We've improved her abduction. External rotation seems to be moving more freely without impingement until 41 degrees of external rotation. Internal rotation seems free. So I thought this would be a very good reconstruction. At this point, I finalized the surgical plan by hitting the subscribe button. Prior to surgery. So the planners were able to develop a surgical plan. These images show the 3D targeter on the patient's scapula, and you can see we could get four of the peripheral legs to seat very nicely, with the standard two legs wrapping around the front rim and the two other feet sitting on the face of the existing glenoid bone. And I was surprised, somewhat surprised to see how well this transfer technology worked in the patient, and how well the surgical plan mimicked the actual anatomy that was encountered at the time of surgery. At the time of revision, I did use some bone croutons to graft some cavitary defects from the screw tracks. I did not encounter any evidence of a chronic infection. There was no biofilm. There was no Seroma noted. I did take five sets of tissue cultures, understanding that this might represent a chronic infection, but I felt I was able to achieve a durable reconstruction that mimicked my surgical plan very nicely. You can tell that based on the overall position and fairly with a little bit of overhang of the sphere in relation to the neck. I think the center post nicely aligns with the floor of the suprascapular fossa, and I like my position on the anterior posterior plane as well, with the sphere sort of covering that posterior glenoid rim. So at latest follow up the patient shows a stable reconstruction with improving clinical metrics. I do believe that the newest capabilities of the VIP system allowed me to plan this case, and feel comfortable with the use of standard implants. Vip turned what could have been a challenging and uncomfortable situation into a definable problem with a definitive solution. I encourage you to make use of this system if you see failed shoulder implants. I believe it will help you plan your surgical plans and optimize your patient outcomes. Thank you for allowing me to present this case.

VIP Vision™: Episode 11—Metal Segmentation for Revision Planning

Misty Suri, MD (New Orleans, LA), discusses patient-reported outcome data from his first 300 cases of CuffMend™ rotator cuff augmentation.

My First 300 CuffMend™ Rotator Cuff Augmentation Cases

Hi, my name is Misty Surrey from New Orleans, Louisiana. I'd like to share with you my experience of my first 300 CuffMend cases. Having done more than 300 of these cases, I've had about an even split between augmenting full thickness repairs and augmenting articular and bursal tear debridement for my patients. My goal is to achieve the best possible outcome with the lowest chance of retear as possible. Cuffmend augmentation gives my patients the highest chance of healing. And let me share with you some of the highlights of the data I have on these patients. So here's my first subset of patients with rotator cuff repair augmented with CuffMend versus the control group. As you can see with my patients who have gotten to the two year follow up time point, there's a significant difference observed the six week mark compared to the control group, and this is maintained until the final follow up. Similar improvements were noted at the three month time point for the aces score, and also for the same score. Similar improvements were observed significantly from the three months to the final follow up. Now, looking at the second subset, which is the rotator cuff debridement with CuffMend compared with debridement only. Now these were 35 patients that got to the two year final follow up time point. Similar trends with pain scores were observed, highlighting significant differences achieved at an earlier time point of the six weeks versus the control group. These results were sustained at the final follow up. Aces scores also improved early on and were also sustained. Seen scores improved in a similar fashion with sustained results. So my PT colleagues noticed patients had less pain and were progressing faster. This is an example of a patient after a medium cuff repair that was actually doing high level military extractions, four weeks after cuff repair with CuffMend.

My First 300 CuffMend™ Rotator Cuff Augmentation Cases

The endoscopic-length whisker blades, compatible with the SynergyResection™ system, provide an innovative solution for effective removal of soft tissue during endoscopic spine procedures.

The endoscopic-length whisker blades, compatible with the Synergy&lt;sup&gt;Resection&lt;/sup&gt;™ system, provide an innovative solution for effective removal of soft tissue during endoscopic spine procedures.

Endoscopic-Length Whisker Blades: Features and Benefits

Endoscopic-Length Whisker Blades: Features and Benefits

At the Orthopedic Technology and Innovation Forum, Patrick A. Smith, MD (Naples, FL), reviews the key lateral knee anatomy involved in anterior cruciate ligament (ACL) injuries and outlines a modified lateral extra-articular procedure that can improve pivot-shift stability.

Next-Level Lateral Extra-Articular Tenodesis (LET)

OrthoPedia: Next-Level Lateral Extra-Articular Tenodesis (LET)

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OrthoPedia: Insertional Achilles Tendinopathies: Literature Review on Evolving Insertional Achilles Treatment

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Dual-View Applications Using the Synergy Vision™ Imaging System

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