This video provides an overview of relevant spine anatomy, including bony, muscular, ligamentous, and neurovascular structures, as it pertains to disc disease.

Spine

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Anatomy of the Spine With Disc Disease

OrthoPedia: Anatomy of the Spine With Disc Disease

James McWilliam, MD, (White Plains, NY), demonstrates the correction of a type III tailor’s bunion, characterized by a widened 4th-5th intermetatarsal angle, using a more proximal osteotomy on the 5th metatarsal, access at the 5th metatarsal styloid, and fixation with a bevel screw. This approach allows for a greater reduction of the intermetatarsal angle while providing a large surface area for fixation.

Foot and Ankle

Not Hidden

Minimally Invasive Correction of a Type 3 Tailor’s Bunion Using a Beveled Screw

Hello, I'm Jim McWilliam from White Plains, New York, and I'm going to talk about minimally invasive surgery on the foot with regards to bunion deformity. So if there's a large intermetatarsal four five angle or if there's significant lateral bowing of the fifth metatarsal, you might want to perform your correction via a more proximal osteotomy. And I'll show you how that's done. And I'll show you an alternative fixation method. Now here we've marked the trajectory of the fifth metatarsal in both the lateral plane and the AP plane. And I'm going to use that sort of as a rough guide for where I'm going to do my fixation. So this is going to be the trajectory of my screw. You can see that instead of being in the high and inside position of a traditional Jones screw, it's going to be going right through the fifth metatarsal Styloid. And I'm going to make my osteotomy where the wire crosses the medial cortex of the fifth metatarsal. So my osteotomy is going to be roughly here more proximal. I might even shift it a little more proximal in that x ray that. So right about there, before the watershed zone of a zone three proximal fifth metatarsal. But we're going to be proximal enough that we're going to get a good level of correction. All right. So we're going to make our incision. I will typically make the incision directly lateral. And that will kind of allow me to do a long oblique osteotomy. I'll use my little elevator. Remember this has the ideal curve to minimally elevate the periosteum dorsally and planoly. To kind of minimize soft tissue disruption but allow enough exposure. All right. So once again I'm going to go straight across just like I have with the other osteotomy. All right. X ray. So I've gone across the I've gone across the entirety of the bone. Now remember there's a declination of the fifth metatarsal. So if I just rotate my hand approximately, I'm going to be cutting distally. And the dorsal cortex. Then I've gone through there. Now, similarly, if I rotate my hand approximately and maybe direct it down just a little bit, I'm going to be cutting approximately. And the planter cortex, you can see I've got my shift there. So this guidewire is a little bit easier to work with. It's the 1.6mm guidewire for the four millimeter beveled screw. And because it's 1.6mm, it's going to be a lot easier to get my direction that I want. So I'm literally starting at the fifth metatarsal Styloid. And I'm going to drive it into the osteotomy line, kind of ideally hugging that medial cortex when I get to the osteotomy. And then we'll check on the lateral and make sure we're in the appropriate orientation there as well. We're pretty good there. So now it's simply going to be a function of moving the metatarsal over and driving the guidewire across the osteotomy and an intramedullary position. So I've got my metatarsal shifted. I've got my guidewire in the right position. So now we're just going to drive the guidewire across. You see how just putting the guidewire in this trajectory across the osteotomy site actually forces the fifth metatarsal medially, affecting your correction. So we've got good correction. We've got good position of the wire in this plane. Let's check the lateral. We've got good correction. You can see I actually cracked the dorsal cortex a little bit with my osteotomy. But we should get good adequate fixation distally without any problem. So now I'm going to use this wire as a guide for my incision. And it just minimizes trauma to the skin and it enhances cosmesis. So I'm going to take the back end of the blade and just push it down. This is an 11 blade. I'm just going to push it down along the guidewire to the fifth metatarsal. So I'm good there. Now we'll take our measuring device. It's beveled to allow us to more closely measure the appropriate depth. We're going to check that the bevel is facing in the right direction. And everything's lined up well. And we still have maintained our medial shift of the distal metatarsal. I'm going to drive this wire out the tip because not only is it our guide for the screw, but it's our provisional fixation and it's just not worth having to do everything over again. We're going to drill over this under fluoro. Not necessarily wanting to go through the medial cortex. All right. We're pretty good there. So if we line up the laser line on the drill with the laser line on the screw, we know what side the bevel is going to be on. Once the screw is buried in the soft tissue, it's just a little visual guide. It only works as long as you keep the driver engaged on the screw. So once the driver is no longer engaged, you're going to have to do it with fluoro. So there's our final fixation our final correction in the AP plane. And there's the lateral.

Minimally Invasive Correction of a Type 3 Tailor’s Bunion Using a Beveled Screw

Tal S. David, MD (San Diego, CA), demonstrates an arthroscopic acromioclavicular repair using the Knotless AC TightRope® system. Visualization is simplified with the use of the Pano™ scope, which enables a 30°, 45°, and 70° field of view without changing scopes.

Shoulder

Acute AC Repair Using the Knotless AC TightRope® System

Today, we'll be demonstrating a knotless arthroscopic stabilization for AC joint separations using the Knotless AC TightRope. We have a right shoulder, our standard posterior viewing portal. We've already established the cannula for the for the for the scope. And we've got our anterior lateral portal. We've started cleaning out some of the rotator interval tissue. And this is an important first step when approaching the coracoid. Today we're demonstrating the new SynergyRF NanoScope, which allows us to scroll through a 30 degree optic, a 45 degree wider optic, and then 70 degree optic. And we'll demonstrate that as we go along here. So we're in 70 degree mode here on the NanoScope. And I've cleared out the base of the coracoid. And it's really apparent how much our visualization can improve with the 70 degree scope. Here's the coracoid base coracoid tip here. It's very rare that we can get all of this in 1 in 1 picture, but it really gives you a sense of how far to get medial, how far to get lateral. You want to be close to your base, obviously not close to the tip. And again, I can do this by just hitting the button and scrolling from my 30 degree to the NanoScope to the 70 degree scope. And it really gives you tremendous versatility in terms of being able to see this. We've established our Subcoracoid vault, which is where we want to visualize the pin coming through. I've got my guide through the anterolateral portal. I'm in 70 degree scope right now. 70 degree mode. I can follow the superior edge of the Subscapular really get a sense of where I am medial to lateral, because this is what I want to establish. You want to avoid coming out here where your to anterior and you risk fracturing the coracoid. And make sure that you're at the base of the coracoid. And again if I want to get comfortable with my position, I can scroll through with the NanoScope with the flip of a button. 30 degree NanoScope view and 70 degree to really get comfortable and place my my drill hole exactly where I want it to be anatomically. We're center center on the clavicle. We've got our guide under the coracoid where it needs to exit at close to its base, and we're going to go ahead and drill this Cannulated drill. You should be able to feel for cortices, the first cortex, obviously the clavicle. And then the base of the clavicle is your second cortex. And then you'll feel that the drill bit drop to the coracoid. Now you're through the clavicle sitting on top of the coracoid through the coracoid. And now we'll see it in our arthroscopic view. We'll see the drill bit come through. And you want to have good control here so you don't dive. And once you get that thing in you can uncheck it from the handpiece. You can remove the remove the guide. You take another view and make sure you're happy with where you are. Again here we're going to scroll through. Our 70 degree can really come underneath it. You can really see that orientation and the location of that. And make sure you're happy that you've got a center center position on the base of the coracoid. So we'll take the cannulation out of the drill bit. There's sometimes a little bone at the end of end of the drill bit when this happens. So you want to make sure you spin it and clear that so your wire can pass without any impedance, because sometimes that can get hitched up down below with a little bone fragment. Once we see the wires in the subcoracoid space, come through with a grasper and bring it out of our cannula. There a wire through. We can then remove our drill bit. You can do this by hand or do it by power. I'm holding the wire so it doesn't go anywhere and he's just going to back it out. So this is our implant. You can see we've got a clavicular button up top. It's pre-assembled with a number six suture in a TightRope configuration. And it's got a passing loop distally that will pull antegrade through our three millimeter drill hole. We'll use our loop suture through the wire. Pulling that down and through in that blue suture is then used to guide and pull through our TightRope. What you want to make sure you're not doing is pulling on these sutures, because you don't want to close this button down and and close your loop prematurely. So I like to keep my fingers on the undersurface of the button just so I can make sure I can maintain my loop length. It makes it much easier to handle that way. And as I pull it through now, I've delivered my TightRope loop here, and this is where I'm going to assemble my dog bone. Once the once the TightRope is past, this blue stitch can be cut off. It's no longer necessary. So now we have our dog bone. It's been assembled onto the TightRope loops. Now we're ready to deliver our dog bone through the cannula. You can see George has got his fingers under the clavicular button over the top, because you don't want to pull the strands and close our loop prematurely. Close our our TightRope loop. And so he's going to give me a little bit of retrograde tension as I walk the button into the shoulder. Now I want to show you something as we get into the shoulder here. And then as I turn to look under the coracoid, I'm going to scroll again through NanoScope in of 70 degree and give myself a really good look, not just of the suture going up, but also that laser line orientation along the long axis of the coracoid. And I know that my button is in the right position and sitting firmly against the bone. That's exactly where I want to be. Now we have our button ready to tension, and we've marked the limbs of our TightRope so that we can make sure that we've reduced this symmetrically between both loops. We're getting a little bit of counter-traction with our probe here, just giving us the ability to control the reduction of the button onto the clavicle. And I'm going to pull an equal amount walking this back and forth, and we get close enough to the clavicle. Now we've got the button almost down to the clavicle. If I want to make any fine tune orientation, I can change it. But I want to use the axis on the laser line to line up my button in relation to the long axis to the clavicle. Once I'm happy with where it is, I'll give it the final tension and pull this down. So here we have the disposable tensioner from the FiberTape Cerclage system. We can use this to help us reduce the AC joint. Makes it a little bit easier instead of having to pull on the sutures. And then we can tension that way. If you look at the arthroscopic view as you do this, you can see the tension we're getting sliding through. You have to be a little bit careful not to over secure this, because you've got a lot of control here. Once you've got the tension set, you can back a little of the tension off with the handle. Makes it easier to remove the sutures and you're set. Once your construct is set, you want to cut the sutures with a three millimeter tail. No need to tie any half hitches or back it up. This construct is biomechanically sound, and that's our technique.

Acute AC Repair Using the Knotless AC TightRope® System

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

MBT as a Definitive Solution After Temporary Relief From Radiofrequency Ablation

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

MBT as a Definitive Solution After Temporary Relief From Radiofrequency Ablation

Rajit Saluja, MD (Franklin, WI), provides technique pearls for treating a bone marrow lesion of the knee with the IntraOsseous BioPlasty® (IOBP®) procedure. Dr. Saluja mixes AlloSync™ Pure demineralized bone matrix and Angel® concentrated platelet-rich plasma from bone marrow aspirate (cPRP from BMA) to treat these defects.

Orthobiologics

Knee

Treatment of a Knee Bone Marrow Lesion With the IOBP® Procedure

I'm Doctor Rajit Saluja, and today we're going to perform an intraosseous bioplastic of the medial femoral condyle. This patient has a bone marrow edema lesion in the medial femoral condyle. We have identified it on an MRI scan. And typically, as we do this procedure, we've already obtained the bone marrow aspirate from the pelvis, typically from the posterior superior iliac spine. This aspirate we typically obtain about 60 cc's. And we use the Arthrex Angel apparatus to obtain the concentrate. This five CCS is then mixed with five cc's of AlloSync, which is the demineralized bone matrix. To that, we combine a cc of contrast which allows us to visualize the injection procedure. Under fluoroscopy, we have the demineralized bone matrix and the bone marrow aspirate concentrate mixture. We've divided them into five one cc syringes. I like to use one cc syringes because if you have multiple lesions, it's easier to subdivide how much total material you have and you can allocate it depending on where the lesions are the largest. We'll start with having our leg in extension. We already completed the arthroscopic part of the procedure. Meniscal debridement has already been carried out. We'll bring the fluoroscopy on an AP view. We'll typically take a spinal needle, find the entry point and take an image. At this point you can see how we're at a good spot here on an AP view. We've already identified the entry point for the injection site, and at this point, we'll go ahead and make a small nick with an 11 blade. This is the Iabp closed tip delivery cannula. I typically use the closed tip because it allows me to fill the lesion more circumferentially. I like to go parallel to the joint line. As you can see, the ends are pointed downwards. Here we'll take our first injection syringe. We'll inject that into the delivery system. Now we'll gradually impact this in. You can see some of the material is coming out on the image. Then I'll rotate the device and get some of the more anterior portion filling. And we'll rotate it some of the posterior portion. We'll withdraw the delivery system a little bit. We'll take another one CC syringe. On the image on the right you can see how the lesion has been filled with the bone marrow concentrate and the demineralized bone. You can get a lot of views at this time. And you can save the images. And you can see how the lesion is filled to your desired goal.

Treatment of a Knee Bone Marrow Lesion With the IOBP® Procedure

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

Hand and Wrist

The Arthrex ElbowLOC® Elbow and Wrist Positioner

The Arthrex ElbowLOC® Elbow and Wrist Positioner

The enhanced instruments and reduced tray size for the Eclipse™ total shoulder system are designed to provide a cost-saving solution through a streamlined operative technique and reduced back-table footprint.

Arthroplasty Shoulder

Making the Best Even Better: Enhanced Instruments for the Eclipse™ Total Shoulder System

Making the Best Even Better: Enhanced Instruments for the Eclipse™ Total Shoulder System

At the East Coast Foot and Ankle Summit, Katilin C. Neary, MD (Boise, ID), reviews bimalleolar equivalent ankle fractures and the clinical decision-making behind intramedullary nailing and deltoid ligament repair.

Ankle Fractures: Literature Review of Bimalleolar Equivalent Fractures

OrthoPedia: Ankle Fractures: Literature Review of Bimalleolar Equivalent Fractures

Prof Dr med Mazda Farshad (Zurich, Switzerland) discusses the case of a 60-year-old male patient who underwent lumbar decompression using a uniportal endoscopic interlaminar contralateral approach at L5-S1.

Lumbar Decompression via Uniportal Interlaminar Contralateral Endoscopic Approach

Hello, my name is Mazda Farshad, chair of Orthopedics and Spine in Zurich, Switzerland. Today I wanted to talk about the smart solution for nerve root decompression, where the traditional transforaminal approach is not straightforward, such as in the Lumbosacral area. This is the case of the 60 year old male patient with acute right sided radicular pain and weakness due to compression of the L5 nerve root due to an upward sequestered disc herniation from the disc l5-s1. In addition, the patient had L5 lysis and segment degeneration. The diagnosis is a disc herniation that was compressing the exiting L5 nerve root through its upward migration. Located in the macnabs hidden zone. The patient had presented to our emergency department for a second opinion. A spinal fusion L4 to S1 with Tlif l5-s1 on the right side was suggested. Elsewhere, we indicated an endoscopic removal of the compression, as the patient was pain free from lumbar pain and had no other symptoms prior to this event. The risk of necessity of further more invasive procedures in future was discussed with the patient. The decision towards endoscopic decompression was made jointly. Since the decompression was at L5-s1, we identified two potential approaches either the iliac crest approach or the uni portal in the laminar contralateral endoscopic lumbar axis, or euestola to access the macnab's hidden zone. As the iliac approach often requires extensive imaging or even navigation for an efficient approach. We chose the UIC la. There is a zone which traditionally is achieved with substantial bone removal in open surgery, often requiring additional fusion due to the iatrogenic creation of instability. The so-called hidden zone is the intra foraminal zone between the two pedicles of adjacent segment. It is covered by the facet joint with endoscopic approaches. This zone has become more approachable in mid lumbar segments such as L2 three, three four and often L4 five. A standard transforaminal approach with Foraminal Tommy by partial removal of the SAP allows access to this hidden zone. However, in certain anatomical circumstances, traditional endoscopic foraminal approaches is challenging or not possible. This can happen particularly at l5-s1, where the iliac crest occludes the trajectory needed for the transforaminal approach. Even if trans iliac approaches have been described, they often require extensive imaging or even navigation for efficient approach. The Une portal interlaminar Contralateral Endoscopic Lumbar Access, or the UIC LA, is an elegant solution to access the macnab's hidden zone. It includes partial removal of the lamina and base of the spinal process to achieve the contralateral resource and foramen to achieve the contralateral recess and foramen. A dedicated trajectory is needed. This trajectory is different from that of a traditional interlaminar laminar approach with the wrong trajectory, visualization and decompression of the contralateral foramen becomes impossible. The skin incision needs to be more lateral compared to the normal interlaminar approach, around 1.5cm lateral to the midline. The trajectory needs to be at least parallel or even aiming from caudal ipsilateral pedicle to the contralateral cranial pedicle in relation to the disc in the AP view, with the starting point more caudal nearly on the lower lamina instead of the upper lamina or the interlaminar window. The bur is used to create the space over the top of the spinal canal, with removal of the part of the base of the spinal process and the contralateral lamina and IIP, and sometimes sap. After thinning the superficial layer of the flavum and sufficient bony resection, the deep layer of the flavum is removed to visualize the contralateral recess. Often, pathologists, such as disc herniations, are located in the axilla of the exiting nerve root, and those are usually not accessible easily with common approaches. The eudicella allows access without destabilising the spinal segment. Once the lateral resource is accessed and visualized via the interlaminar contralateral approach, the medial border of the dura is identified and followed cranially to find the axilla of the exiting nerve root. Due to the angulation of the approach, the axilla is found by rotating the scope to visualize laterally towards the foramen. Any compressive tissue can be removed easily. Final inspection of the hidden zone includes visualization of the exiting nerve root within the foramen, contralateral recess, and the descending nerve root. The patient presented with reduced pain and improved foot drop in the weeks after surgery. Our postoperative protocol included standard analgesics and some advices for physiotherapeutic treatment. Through this treatment option, the patient was able to avoid spinal fusion.

Lumbar Decompression via Uniportal Interlaminar Contralateral Endoscopic Approach

Thomas Youm, MD (New York, NY), performs a core decompression for avascular necrosis (AVN) of the femoral head using the AVN expandable reamer and AlloSync™ Pure demineralized bone matrix (DBM).&nbsp;

Core Decompression of the Femoral Head Using the AVN Expandable Reamer and AlloSync™ Pure DBM

We are here today to show core decompression of the femoral head for avascular necrosis. The idea behind core decompression is to prevent eventual total hip replacement. We describe a technique that allows for seamless delivery of biologics and bone support into the core decompression tract. These are some examples on imaging of avascular necrosis of the femoral head. We have an x ray AP left hip showing avascular necrosis of the femoral head. Also MRIs both T1 and T2 views of the AVN of the femoral head. The indication for core decompression is to not have any subchondral collapse. In the presence of a crescent sign. You can see the crescent sign on the MRI images on both T1 and T2. We are here at the back table to show you the instrumentation for the core decompression set. We have both reusable and disposable instruments. The disposable instruments include A24 guide pin, A50 reamer, expandable reamer which is torque limited, as well as the application guide for the biologics. For the reusable guides, we have the drill guide with a handle drill guide insert, as well as a t-handle with a torque limiter. Critical part of core decompression is consideration of biologics. These are the biologics that I use. We have the Arthrex, BMA, vortex threaded needle Allison Pure. We have the Kwikset cement. What we do is with the BMA needle draw the bone marrow aspirate, mix it with the Allison Pure to fill the cavity of our core decompression to allow for healing. The quickset is then used to backfill to allow for to prevent leakage of the BMA. This specimen has been prepared with a flush fit cannula inside the joint. We're focusing on the open technique, but we will show arthroscopic pictures of the femoral head in preparation for our technique. I draw my landmarks. We see here is the ASIS with the iliac crest. I draw the inner and outer tables. I'm drawing the anterior femur, posterior femur and the tip, the greater trochanter. I use the Arthrex vortex needle to get my bone marrow concentrate. I do this early in my case so that the bone marrow concentrate is ready to be mixed with the allicin pure to share a pearl that I use to get my targeting and keep the incision small. I lay a guidewire right on top that you can use a 2.4 guidewire from the set. And I want to get my angle. If you can take a c-arm shot here. Another one? Another one. Right. And most lesions are anterior superior. So we'll mimic that in our demonstration today. We are going to draw a line right over the guidewire towards the femur. And that will give us an idea where we're going to start our incision. Next thing I'm going to do to see our starting point is I'm going to poke the guidewire or guide pin right on the femur if you can take a shot there. And another shot there to see on our starting point. So I like my starting point here. I'm also seeing the posterior aspect of the femur where we're going to start a little bit posterior on our incision. I can feel anteriorly, so I know I'm in a good spot. This is where I will center my incision. This will be my incision for our core decompression. So I have my drill guide right on the lateral cortex. And I'm bringing my guide pin right inside. Let's have a shot here. We have our guide pin in appropriate position. As you know, most femoral AVN lesions are anterior superior. You can see we're somewhat superior to the central portion of the femoral head. Now that we have our guide pin in appropriate position on the AP short of the articular surfaces, we're going to check a lateral view accurate targeting of our guide pin into the AVN lesion which is typically anther superior, is critical for this case, with multiple fine adjustments, we see on the lateral view of the hip that our guide pin is somewhat anterior from the center point, which is exactly where we want. Now that the pin is in good position, we are going to take out the drill sleeve and put the cannulated five millimeter reamer over the drill. As we get to the subchondral bone, the bone will feel stronger and more sclerotic. Shot, please. And it's important to make sure you're not engaging the guide pin in the reamer so as to not advance that guide. Pin through the cartilage. Shop, please. Shop, please. Right there. At this point, we're going to advance the stepped five millimeter, five millimeter drill sleeve using our slotted slap hammer. Shot there. Okay. So here we see that the step collar is flush with the cortex. And at this point the sleeve is appropriately inserted. So at this point we will take out the reamer first and then the guide pin. So this is the torque limiting expandable reamer just to show you how it works. This black knob here is to expand it from 6 to 18mm. So to prevent premature deployment of the blades inside the the bone, we hold it right behind the black knob. No pressure from posteriorly on the t-handle and we insert. And we'll confirm with C-arm to make sure that we're at the appropriate position and depth. It's important to note when you use this reamer and start expanding, go up one notch at a time. Have at least a few turns, and if you're feeling a lot of chatter, don't get. Don't prematurely advance too quickly. So here I'm at six millimetres. Turning over to nine. And this is at maximum expansion shot there please. One more time. Good. All right. So now that we're at 18mm, we want to check on the lateral view, which we did to confirm appropriate position. And here what I'm going to do now is I'm going to withdraw this back and still turn to get chatter so that we can create more decompression of that avian lesion. If you can take a calm shot, please. So as we pull this back and keep turning at 18mm, we're creating a larger cavity for filling of our allosyncarpia with bone marrow concentrate. Take a shot, please. And you can hear the chatter shot again please. Good. All right. So at this point I'm going to bring our reamer back down to six and we'll pull this out shot there. At this point with the reamer out, it's a good idea to flush out any necrotic bone and tissue. We use the applicator from our disposable set to insert. Take a shot, please. Calm. One more. Good. I'll remove the inserter at this point. Insert syringe with saline shot again, please. And we'll just flush it out under some pressure. Okay, so this is our 250 millimeter nanoscope needle. We're going to take a look inside our decompression tract and our tunnel to see if we got to the sclerotic bone and necrotic bone. Obviously in this cadaver model you won't see the necrotic bone, but you can see very clearly a very good resolution of the intraosseous space. At this point, we have five CCS of our Allison Pure with five CCS of bone marrow concentrate. I will mix this in a 1 to 1 ratio. I also have the quick set here ready to go. Once we are done with our Allison Pure mixture, we get the quick set ready for backfill preparation. We have our biologics applicator, which we're going to insert into our drill sleeve and we will confirm appropriate depth. I like to be right at the entry point of the cavity. Take a shot please. Good. Take a shot, please. So, right at the entry point of the cavity. I've taken my five cc slurry of bone marrow concentrate and allicin pure and transferred to one cc syringes, which we have here. These will secure themselves to our applicator, and we'll start injecting in the beginning. There's not much resistance because we're just filling our applicator. But once we remove once we insert our plunger, we'll start to see this mixture go into our decompression tract. So I recommend using the plunger slowly so as not to penetrate the articular surfaces in case there's any chondral fissuring. Yeah. X ray please. X ray please. Yeah. You can see filling. I'm getting a little bit of resistance here. I'm going to pull back our applicator x ray please. X ray please. All right. So we got nice filling there. Now what I'll do is just for the backfill for the quick set I'm going to retract our applicator back further x ray please. Right about that level. Okay. Now we have our quick set that's been transferred to a syringe for easy application. I'm going to insert that right into our applicator. And we're going to inject that in. All right good. We'll finish that in. And then we're putting the plunger in here to complete the insertion of the quick set and chat there. Good. Once we're in we'll take this out and we'll take our whole system out at this point. Shot again. Very good. So at this point the surgery is complete. We will have post-op images that will show on x ray. Our decompression tract filled with Kwikset as well as the bone marrow concentrate with Allison Pure, have an x ray view here. We'll also have an MRI view of the decompression showing filling over time. I also have a bilateral hip MRI where a patient has AVN on both hips. On the right hip, you can see there's still bone marrow edema from the AVN on the left hip. This MRI was done over a year after surgery. You can see complete bone healing and no evidence of any necrosis on both AP coronal as well as axial views. As you can see, the core decompression surgery we performed today was done under a minimally invasive technique with about a two centimeter incision. Appreciate you taking the time to watch our video today. Thank you.

Core Decompression of the Femoral Head Using the AVN Expandable Reamer and AlloSync™ Pure DBM

The ACP Max™ system provides efficient concentration of platelets and growth factors from platelet-rich plasma (PRP) for use at the patient’s point of care. Expanding on the previous generation of PRP devices, the ACP Max system allows for a larger blood draw and provides increased platelet concentration using a unique double-syringe, double-spin design.&nbsp;

ACP Max™ Platelet-Rich Plasma System

ACP Max™ Platelet-Rich Plasma System

Hussein A. Saad, MD (Dearborn, MI), demonstrates a single-portal technique for repairing a posterior labral tear using Knotless 1.8 FiberTak® soft anchors. He passes the nitinol wire from the SutureLasso® suture passer through the capsulolabral tissue before drilling and inserting the suture anchor to minimize suture management steps.

Single-Portal, Posterior Labral Repair Using Knotless FiberTak® Soft Anchors With Minimized Suture Management

Single-Portal, Posterior Labral Repair Using Knotless FiberTak® Soft Anchors With Minimized Suture Management

The PARS Achilles Midsubstance SpeedBridge™ implant system is a percutaneous, minimally invasive technique used to repair Achilles tendon ruptures. Using color-coded 1.3 mm SutureTape, the PARS system makes it easy to create a percutaneous locking stitch in the Achilles tendon, while staying inside the paratenon sheath.

Achilles Midsubstance SpeedBridge™ Surgical Technique

When using the parse jig for the Achilles mid substance SpeedBridge technique, a percutaneous incision is made in a transverse manner just proximal to the palpable rupture. Alternatively, a small longitudinal incision can be utilized. The tendon is grasped and the jig is inserted with the inner arms inside the peritoneum of the Achilles tendon. The first parse needle is placed in the number one hole in the jig to stabilize the construct, while passing the other needles and sutures in sequential order. Lastly, the white SutureTape is then passed through hole number one. The jig can then be removed, which pulls the sutures out of the incision. Separate out each of the five sutures, the white, blue, and black suture tapes, as well as the two green and white FiberLink sutures. Each suture should be tested by pulling light tension through ten cycles to confirm appropriate hold in the tissue. On both sides, past the blue SutureTape under and around both green and white. Fiberlink SutureTak twice and back through the loop, then advance each loop back through the tendon using the free end of the green and white FiberLink sutures. This creates the locking stitch. Two stab incisions are made one centimeter below the superior aspect of the posterior calcaneal tuberosity. Medial and lateral to the Achilles tendon. Within these two stab incisions, insert the guidewire utilizing the drill guide with the white centering sleeve at 45 degrees from the centerline of the Achilles in the coronal plane, and 45 degrees from posterior to anterior in the sagittal plane. Guidewire placement can be checked under fluoroscopy. These two holes are drilled with a 2.6mm drill and tapped for later SwiveLock insertion. A banana. Suturelasso is passed through the distal stump of the Achilles and out of the rupture site. The SutureTape from the proximal portion of the tendon are then passed through the distal stump and out of the stab incisions distally. The suture tapes are then loaded through the eyelet of the Rd 3.9 biocomposite SwiveLock anchors. The foot is plantar flexed 10 to 15 degrees to approximate the tendon ends. The SwiveLock anchor is placed into the prepared hole to secure the suture tapes. The laser line feature on the SwiveLock shaft can be utilized to confirm when the anchor is flush, or two millimeters countersunk. The same steps are repeated for the suture tapes on the contralateral side. The incision is closed. Jumpstart antimicrobial dressing can be utilized and the result is a secure knotless repair of the Achilles tendon rupture.

Achilles Midsubstance SpeedBridge™ Surgical Technique

Mazda Farshad, MD (Zurich, Switzerland), performs a posterior endoscopic foraminotomy at the C4-C5 level.

Cervical Foraminotomy

My name is Mazda Farshad from Zurich, Switzerland. We are performing a posterior endoscopic cervical foramina. The patient is positioned like for a standard posterior approach of the cervical spine. You can use a Mayfield frame to fixate the head. Fluoroscopy is positioned 90 degrees to the patient. This is cranial. This is caudal. So we start first by palpating the midline and drawing the midline. Once the midline is identified by palpation and the line is drawn, we make a lateral fluoroscopy shot to identify the level that we're aiming at here we're aiming at levels four five. So we want to aim towards the disc of the level that we're aiming at. That would be level four, five and 90 degree to the spine. We can then insert the needle. The needle should be inserted approximately one centimeter lateral to the midline. This will allow that later on we can have a nice view on the foramen. Now we want to aim a little bit higher. Approximately 2 to 3mm higher to be able to palpate the upper lamina. That would be the lamina number four here. Once we're happy we cut the skin and do. Skin incisions in a vertical direction from cranial to caudal. So that conversion to open surgery would be possible at any time. Once this is done, the K-wires is installed. Make sure that the K-wires is vertical to the floor 90 degrees. Otherwise, adjust the patient and the table. By Trendelenburg or anti Trendelenburg to achieve this position. After that the dilation is done. This can be done stepwise or directly using the switching stick already with the switching stick. You can palpate the upper lamina Over the switching stick, the canyon can be inserted. A fluoroscopy shot will verify that we're on the right level with the switching stick inside, the lamina is freed up from muscles by going from medial to lateral using the sharp edge of the cannula, then the switching stick can be removed. Now we see the position of the cannula aiming at the disc four five, where we want to be at in approximately 90 degree angle to the cervical spine. Once this is done, we could insert the endoscope. For purposes of visualization, we will now do an AP view. The AP view can be used if one is unsure about medial lateral position of the cannula. The endoscope can now be inserted. And make sure to control the cannula so that it doesn't move. And now the soft tissue can be removed with a large pituitary. So the soft tissue is removed and we start to see the upper lamina C4, the bone of the upper lamina. Here we remove a little bit more soft tissue and identify the lower lamina of C5. Here with the bipolar we can clean up the soft tissue nicely and palpate the upper and the lower lamina. So the upper lamina here the medial border the lower lamina. And then we start to identify a V form. This is the so-called V sign formed by the upper lamina and the lower lamina. And this is the entrance to the spinal canal. Here we already see the ligamentum flavum. So now we want to turn the V into a U by using the burr. I usually start with the upper lamina and then we go. We proceed to the lower lamina. Make sure to remove enough of the lower lamina. No pressure on the burr, but more on the cannula if you want to manipulate the position. So now we have removed the bone and converted the V to a U. A little bit of the upper lamina. More on the lower lamina so that actually the ligamentum flavum, the attachment is disconnected to the lamina. Here we see we are already in the spinal canal. And we can start dissecting the ligamentum flavum from caudally to cranially. Once we have disconnected the ligament from the lower lamina, we can use a kerrison to remove it in a stepwise fashion. Before that, you might want to go more lateral by removing more bone. So then we can change the view a bit to resect the ligamentum flavum. I use the kerosene for that. Make sure to turn the scope so that you verify that you're just removing ligament and nothing else. The aim is to visualize the lateral border of the dura. The best view to remove the flavum towards medial is from caudal to cranial, so you can turn your scope around 70 to 90 degrees to visualize the opening of the kerosene to be able to remove the flavum safely. The identification of the lateral border of the dura is extremely important in order to identify the nerve. Once we have identified the lateral border of the dura as seen here, we can basically glide up to the nerve root, and here the nerve root is identified here. We are now in the axilla of the nerve root. The same can be done from cranial to caudal. Identifying the shoulder of the nerve root as demonstrated here. So now we see the dura, the lateral border. The axilla of the nerve root at this condition would be accessible here. And the shoulder of the nerve root here we are pointing towards the foramen. So with the ball tip we can palpate also the pedicle. Here we are palpating nicely the pedicle of the lower vertebra which is c5 in our case. The ball tip can also be used to carefully palpate into the foramen. Once this is done the foramen can be visualized By turning the scope facing the foramen. Once the nerve root is identified, we have to look into the foramen. For that, we position our canal either on the upper or the lower lamina, and turn the cannula and the camera in order to visualize the nerve, as demonstrated here. So now we're looking into the foramen, and we can use our kerosene to remove some more bone. You can always turn your camera to be able to have a better look for verification of a full decompression. Use your ball tip to palpate along the nerve root. So here we have the nerve root and the foramen which is now freed up. This can be also visualized from another view looking how the cranially. Here again we have the lateral border of the dura. The axilla. And here we are in the foramen. And now I'm palpating all through the foramen, making sure that the foramen is fully free and the nerve is decompressed. Once the decompression is completed and you have verified that visually, and also by palpation, you can pull out your camera and your cannula and close the skin with 1 or 2 stitches. Posterior cervical endoscopic approaches allow decompression of the nerves by foramina or and or discectomy. This is not a beginner level surgery for endoscopy. It allows to avoid acdf in many cases, can usually be performed within 45 to 60 minutes in an outpatient setting.

Cervical Foraminotomy

G. Russell Huffman, MD (Orlando, FL), reviews key literature supporting biologic rotator cuff augmentation in addition to discussing how graft choice may affect retear and reoperation rates.&nbsp;

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