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INFORMATIONSMATERIALIEN FÜR KUNDEN

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.

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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)

The Arthrex Elbow Fracture Plating System provides a comprehensive portfolio of distal humerus and olecranon plates. Designed to treat all fractures, the set comes with KreuLock™ locking compression screws, allowing the surgeon to both reduce the plate to bone and compress across a fracture. The plating portfolio is perfectly complemented by Arthrex soft- tissue procedures and fracture reduction, including LUCL/MUCL InternalBrace™ ligament augmentation, FiberTape® cerclage, and the ElbowLOC® elbow positioner.
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.

The Arthrex Elbow Fracture Plating System

The Arthrex Elbow Fracture Plating System

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

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

Peter J. Millett, MD (Vail, CO), uses the Knotless 1.8 FiberTak® implant system in a cadaveric demonstration of a knotless Bankart repair. Dr. Millett reviews a range of tips and pearls from portal placement to sequential repair tensioning. Tensionable Knotless FiberTak implants of varying colors provide multiple points of fixation to restore anatomic tension to the glenohumeral soft tissue.

Tensionable Knotless Bankart Repair Using the Knotless 1.8 FiberTak® Implant System

Hello, I'm Peter Millett from Vail, Colorado. Today we're going to demonstrate an arthroscopic bankart repair using the 1.8mm Knotless fiber implant system. So we've established our posterior portal, and I'm going to demonstrate the new five millimeter percutaneous cannula. I'll put a spinal needle in first. And then this can be placed over a guidewire. So it allows you to place the anchors wherever you want. So this will be a high one here. At this point I'll have my assistant just hold the scope. We'll pull out the center portion of the needle, feed the little wire down. We'll just make a little nick in the skin. Here for about 4 to 5mm is usually sufficient. And then this cannula can just go right over it. And you can place this anywhere, anywhere you need. And the nice thing is that the 1.8 anchors will fit through that. Great. So that's our first portal there. So now we've established our second portal here. This is an 8.25mm cannula. I like to put it just over the subscapularis. Usually you can reach most of the glenoid with with this approach. Occasionally, if you need a really low anchor, you can go in percutaneously using this five millimetres cannula with the same technique. But in this case, I think we'll be okay with these two two cannulas. The more medial this is, the easier it is to pass it around the tissue. The more lateral it is, the easier it is to insert your anchor. So you have to kind of take that into consideration. Then what we'll do is we'll mobilize all the labrum and the capsule here, which we've done. My assistant just kind of pull back on the arm a little bit. And that helps to visualize that. Sometimes we use a 70 degree scope or this scope viewing from the back, just to help us see this as well. You want to have it mobilized until basically you can until you can see the subscapularis fibers underneath it. Now we're going to demonstrate putting our first anchor. And this is the curved guide for the 1.8mm anchor. We'll place it in through our lower cannula here. If you put the obturator in, it just helps to decrease any fluid extravasation. And then once it's in position, ideally we'll get it up on the glenoid face. And then I'll tap it with a mallet just to secure it on the glenoid here. And then we'll come in with the flexible drill. And then usually this is this phone's kind of soft, but in a young patient, I would cycle the drill 3 to 4 times to make sure you clear all the bone debris out of it. Now, we'll come in with our with our anchor. This is the 1.8mm knotless fiber tack anchor. And there's a little recess in the in the drill guide here. And it's important to line the little handle here up with that so that it slides down properly. And then we'll insert it by hand for a few millimeters and then finish it off by tapping it in place. And this just bottoms out on the inserter. I'd like to just check the prongs, make sure they're intact, and then we'll remove the inserter at that point, and then we can pull back on the anchor and make sure that it seats properly. So now our anchor is inserted. You'll see that there's three sutures in this 1.8mm knotless fiber tack anchor. The repair suture in this case is blue. They come in different colors in this system to help with differentiating suture management. But you want to retrieve the repair suture out through the superior cannula, and then you'll leave the shuttling suture here in place out through the inferior cannula. And try not to touch these sutures very much so that they don't get extra twists in them or get damaged at all. At this point, we'll then come in with a lasso. This is a 25 degree left curved. So what I do is oftentimes I'll just kind of stabilize the tissue with the grasper. And then I'll come in perpendicular to the capsule and pop through and then rotate my hand around until I see it in the defect there, and then retrieve the. Retrieve the wire out through the superior cannula. Then at this point, we'll just shuttle this repair suture back through around the capsule and labrum, and you untwist this. Then we'll just retrieve that repair suture out through the capsule and labrum. And again we try not to twist these at all. So there that's out. Now one thing I do is I just kind of milk the suture a little bit to take any longitudinal twists out of it. And then I'll put this park this over to one side, and at the same time I'll take the shuttling suture here, separate that. I always separate it from the cannula out. So I'm not putting twists into it and then move it back and forth. Some people call it a floss technique, and then we'll take an extra suture. At this point this is a counter-traction suture. Shorten the loop here and then we'll we'll pass our repair suture through through the loop and then fold it. There's a little mark purple mark right there. Fold it to that point. Now I'm just going to convert the suture. So I'll just do this kind of start off slowly. Make sure the suture is entering the cannula properly. And then just pull it out. That converts it. Grab the end of the repair suture. And then at this point now I can pull back on this traction suture. It puts tension into the loop and it makes it go in nice and smoothly and without any twisting. And you can see that I'm going to back up here so we can see that being delivered into the joint here. So there you can see it. It's getting get it pretty close. So just before we tighten it up finally what I can do is I can come in with my grasper again and just grasp the soft tissue and pull it up and reduce it like that. Pull it tight. You see, you still have this traction suture here. We can remove that at this point. And we can use that again. Use it over and over again for the next ones. And then we'll just do our final tightening here. And we've got a nice shift and we've got a nice restoration of the capsule labral junction and nice bumper in the front of the shoulder. So at this point you have the option to either cut the suture or you can leave it and then do sequential tensioning. I think if you're going to do sequential tensioning sometimes taking this out of the cannula can be helpful. So you don't get tangled on the other sutures. So just put a switching stick in, pull the cannula out and then we can grab the suture. And then we can put the cannula back in. And now we have our suture kind of out of harm's way. And we can put our next anchor in without without worrying about getting tangled or twisted. Great. So we've got our first anchor in. Now we're going to place our second anchor. This one's a little bit easier. Usually the lowest one's typically the most challenging. Typically we'll place it about the first one around 5:00, then 4:00 and 3:00 or so. Place the guide in place. Tap it up on the face of the glenoid. Secure it and we'll come in with our flexible drill. And then it's important to pull the drill back beyond that little opening in the. In the insertion sheath so the bone debris can be removed from the. From the tunnel. And at this point then we're going to come in with our second 1.8mm knotless fiber tech. This one has a different color repair suture. So we'll be able to distinguish those again. You'll line up this with the the recess part of the inserter here so that it goes around the curve properly and then insert it by hand initially for the first few millimeters to get it started, and then tap it in place. Remove the grommet. Tap it to disengage it. I'll come in with my retriever. This is a mini kingfisher retriever. And again you have your repair suture and then you have your shuttling suture. So the repair suture in this case is is white and light blue. So we'll retrieve that separately out of the superior cannula. And again now we'll come in with my 25 degree left curved lasso I hold the these sutures tight so I don't damage them at all while I'm inserting this. And I'll just back this wire up. And at this point I can grab this tissue, kind of pull up on it a little bit so it has good tension. And again, go perpendicular to the capsule and come around, hit the glenoid, and then we'll pop through just below our anchor and then retrieve the retrieve the wire out the superior cannula. And then we'll shuttle our repair suture back down through through the cannula and then around the capsule and labrum. Okay. So at this point again we'll we'll separate these sutures so that it's so that they don't get twisted. Just put the repair suture to one side and the shuttling suture to the other side. Strip this a little bit to make sure there's no longitudinal twists in it. Now we'll come in with that counter-traction suture. So this goes between goes between those two sutures, between the repair suture and the shuttling suture. Now we'll just convert the anchor. So again you fold it over. There's a little blue mark right there that's appropriate. And then at this point we'll convert it. And now we have this this traction suture. Again it makes it a lot smoother a lot less chance that you're going to get tangled or twisted. And it really just makes the procedure a lot, a lot simpler. So at this point we have our suture almost fully tensioned. I'll come in again and grab the soft tissue, and I can get it right to where I want it to be. And then at this point, I then can remove that traction suture, and then we can get the final tension on our repair stitch here, and we can retension our first one if we want. And so you can get a little bit more tension out of that. So now we've completed putting all our anchors in. This is our lowest one here, our middle one, our second middle one and our top one. We put four anchors in this repair. I usually use four. Sometimes if it's a really big tear, even five, you can see how it's restored the capsule labral tissue here. Now what we'll do is retrieve our repair sutures so that we can go ahead and tension them again. We'll pull them all out through the cannula, and then after that, after we tension them, we'll we'll then go ahead and and cut each suture. So we'll just start at the bottom here you can see we can retension that a little bit. We looked at this in the lab recently and showed that you get about an extra millimeter or so when you do this. Because as you can imagine, as you pull each suture up and put each anchor in, it helps to spread the force over the whole construct. So there we've tensioned each one individually. So now they're all tight. So at this point we'll then we'll just cut each one sequentially. Just a little pearl. When you're using the cutter it's always important to cut it right in the center. You don't want to cut it off to the side like that. You'll get frayed edges. So cut it right in the center. Here's our our final repair for anchors for bankart repair. This is with the 1.8 Knotless. Fiber tech gives a very nice low profile repair. You get multiple points of fixation, minimal bone resection, very strong. You can retention it at the end as well, which I think is a nice advantage. Hope this helps you in the care of your patients. Thanks a lot.

Tensionable Knotless Bankart Repair Using the Knotless 1.8 FiberTak® Implant System

This animation demonstrates capsular closure at the end of a hip arthroscopy procedure using a SutureCast™ suture passer to pass 1.3 mm SutureTape sutures.

Capsular Closure Technique Using a SutureCast™ Suture Passer

Capsular Closure Technique Using a SutureCast™ Suture Passer

Asheesh Bedi, MD (Ann Arbor, MI), demonstrates a comprehensive cam resection of the femoral neck using the Hip DiamondCut™ burr.

Femoral Neck Cam Resection Using the Hip DiamondCut™ Burr

Today, I wanted to feature two great products that you have as part of your armamentarium for hip arthroscopy and preservation surgery from Arthrex. And that's the four and the 5.0mm diamond cut burs. So here's a close up. Some of the huge advantages here is its ability to work as a finishing bur. It can function well on hard bone or soft bone with great control and precision, and it avoids skipping, which is sometimes what happens on those harder surfaces with a fluted bur. It works reliably in both forward and reverse. Another advantage over fluted technology is sometimes the ability for it to protect and not wrap soft tissue in the capsule, which is at a premium during hip arthroscopy. All right. So now we have this more focused view. And just to orient everyone this is a right hip. We've completed our central compartment work as you can see here. Nice labral repair using the knotless fiber tack anchors getting a good suction seal of that labrum. And now we're just working to our peripheral compartment. There's our acetabular sided capsular limb and the rectus. And here's our femoral capsule here. And we can now start to demarcate for our camera section. Generally speaking for me I like to start superolaterally here right adjacent to the labrum. And here with this diamond burr, we can set a margin. But again, one of the advantages here is this nice demarcation and control even on hard bone in a young patient where we can set an edge and you can see it doesn't skip. I tend to use the labrum as a guide to set that physeal scar. And here I'm just going to work to define that margin of our proximal resection. You can work fairly closely here to the acetabular edge here. And again based on the position of flexion you have, you can set that margin rather nicely here. Here as we go a little bit more anteriorly I come a little further away from the labrum to set that normal angle of the physeal scar. As you can see that defines that nice proximal edge. And we know that everything proximal to that we're going to designate an important weight bearing cartilage. I'll sort of deliberately here, as you can see come in close proximity to this femoral sided capsule. And you can see not only does the hood protect us, but this diamond surface is not wrapping up that capsule as I work in close proximity, which is more likely to occur with your fluid at burs. From there, we can continue to work our camera section here. I can switch deliberately here from reverse to forward, no difference in its efficiency in resecting and setting that margin for our camera section working here from proximal to distal along the edge. We'll continue to work here. You can see here nicely. We can work right next to that labrum with good control. I'm basically abutting the labrum here laterally and can continue to work right around the corner here, even superolaterally up near our retinacular vessels. Here we can change our view a little bit. We'll rotate our eyes. You can see here we can work more medially. Oftentimes this bone here medially is a little bit softer. And this is where the fluidic bur can sometimes gouge or resect particularly in softer bone. But here our diamond burr has excellent control as we continue that resection working from proximal to distal right here towards our capsule. As you see here as I'm resecting bone, one huge advantage is we're not getting the snowstorm effect or the snow globe effect, which can sometimes obscure your view. I'm modulating the suction here, but I have an excellent view and control the entire time. And that polish and design of that diamond burr surface has specifically been designed to minimize the risk of that snow globe effect. You can see here we're working in the camera section from proximal to distal. And I can continue to work my way distally preserving this proximal convexity and then working distally here now to a more concave resection. At this point as I'm continuing to push the capsule away, I think you can see nicely even without changing the leg flexion. I'm not wrapping up the capsule at all. As we continue that resection medially and distally. Just for a moment, I'll show the view. Here you can see where we've defined that proximal margin of resection. Nice margin. And we can continue to work distally here. So as you can see we've continuing our cam resection. We've set our proximal margin. This actually is a pretty good view as you can see here of the Cam lesion. This loss of offset here and asphericity here. As we move over that direction you can even see your superolateral extent of the Cam lesion. Those are your perfusing retinacular vessels there. For the sake of this video, we've deliberately done a little mini T here so that we can see and visualize this camera section to show the value of this burr, But here I can work with great precision and even drive here up in superolaterally work right next to the labrum with great safety. Here I'm going to continue that resection proximally. And here we can work right up and next to the retinacular vessels here and actually remove that bone without worrying about winding up those vessels, even those anterior perfusing vessels. Then here, as we work our way back, I can set another margin here of resection. Again. Good control. It doesn't skip. Finishes medially and laterally with precision. And we'll continue to define that cam lesion so that we don't stop proximally. But we restore that offset here distally all the way along the head and neck junction as well. You can see it works very well working from proximal to distal. And we'll continue to work distally right here towards the distal neck. So we feel like we've restored normal sphericity and offset in all of these different planes. I'll deliberately here bring the the bur as I wouldn't right up on the capsule here deliberately try to wrap up the capsule with the bur. And if you notice it's avoiding that wrap up even when I'm intentionally trying to go towards and blur the soft tissue. It just won't wrap up the tissue the way a fluted burr does. So truly an inherent additional layer of protection to protect the capsule for your later closure. So, as you can see here, as we've progressed through our camera section, we've got a nice proximal demarcated margin for the weight bearing cartilage. We've restored offset and sphericity here in the area of the typical Cam deformity. We've had a great control here with this diamond burr. You can polish out any areas as you're inspecting around to make sure that you've been thorough in all planes. You can actually see a little impingement cyst here that we have great control over to make sure that we've gone to the right depth there. So this is a nice and thorough camera section that's well controlled using this diamond Burr technology that allows us to do an excellent pincer resection proximally and an excellent cam resection distally. Now, as you can see, because we've preserved our capsule so nicely, we can just come here and nicely repair this mini T side to side working from here to here. And then we still have our proximal capsular flap for our inner portal closure.

Femoral Neck Cam Resection Using the Hip DiamondCut™ Burr

The revolutionary TightRope SB™ implant eliminates metal hardware from ACL reconstruction procedures and features a suture-based button for cortical fixation. This animation demonstrates a QuadLink™ ACL reconstruction using the FiberTag® TightRope® SB implant with the InternalBrace™ technique.
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.

QuadLink™ ACL Reconstruction With the FiberTag® TightRope® SB Implant and InternalBrace™ Technique

The Quad Link SP construct features a revolutionary suture based fiber attack tightrope SB implant to treat ACL injuries without metal hardware. The fiber tagged tightrope SB implant uses a radiopaque all suture cortical button that provides improved strength with a minimally invasive, low profile design compatible with existing arthrex retro construction and tightrope drill pin socket drilling techniques. The comprehensive line of tightrope SB implants accommodates all graft types and are available with preloaded radiolucent or radiopaque fibertape suture for the internal brace technique, allowing surgeons the flexibility to leverage cutting edge tightrope technology with the graft and technique best suited to the unique needs of every patient they treat. Place the ACL femoral guide over the ACL femoral footprint arthroscopically. Adjust the angle of the guide to the desired position and tunnel trajectory, and then lock into place. Push the ratcheting drill sleeve down to bone. Advance a flip cutter three drill pin through the ACL femoral footprint. Tap the tapered portion of the drill sleeve into the femur seven millimetres or until resistance is felt when reaching the femoral cortex. Using the, we'll deploy the flip cutter three drill to the appropriate size and retrograde drill back to the sleeve to create a socket. Remove the flip cutter three. Drill and pass a blue and white fiber. Snare suture through the drill sleeve. Retrieve it from the lateral portal and dock it for later graft passage. Remove the drill sleeve. Place the ACL tibial guide over the ACL tibial footprint. Arthroscopically. Adjust the angle of the guide to the desired tunnel position and tunnel trajectory, and then lock into place. Push the ratcheting drill sleeve down to bone. Advance the flip cutter three. Drill through the ACL tibial footprint. Tap the tapered portion of the step drill sleeve into the tibia seven millimetres or until resistance is felt when reaching the tibial cortex. Using the, we'll deploy the flip cutter three drill to the appropriate size and retrograde drill back to the sleeve to create a socket. Remove the flip cutter three. Drill and pass a black and white fiber. Snare suture through the sleeve. Retrieve both the fiber. Snare sutures from the medial portal, and remove the stepped drill sleeve with the blue and white fiber. Snare suture. Pass the femoral side of the quad link. Construct into the femoral socket, keeping the white and black tiger wire suture under tension to elongate the all suture button until it flips on the femoral cortex. The fibertape internal brace, suture, or tibial tightrope loop can be pulled to confirm deployment. Use the white tensioning sutures of the tightrope SB implant to advance the quad link construct into the femoral socket. With the black and white fiber snare suture, pass the fiber snare suture for the internal brace technique. The white tightrope tensioning strands and the blue leader suture into the tibia. Maintain counter tension on the tiger wire. Suture to elongate the SB implant while shuttling the fiber. Snare suture distally. Pull on the inside of the fiber tag tightrope SB loop to advance the graft into the tibia with the knee in extension, pull on the white shortening strands to advance the soft button down to bone before tensioning the quad length. Construct. Anchor the fibertape sutures for the internal brace technique using the ACL Back-Up fixation Kit. Using the spade tip drill followed by the 5.2mm tape. Place the fibertape suture for the internal brace technique into the eyelet, and screw the 4.75mm swivel lock anchor into the drilled hole. Take the knee through range of motion before fully tensioning the quadling construct. The knee can be cycled several more times and both implants re tensioned to alleviate residual creep. The tiger wire and fiberwire sutures can be removed. The tightrope tensioning strand can be cut, flush or tied over the soft button based on surgeon preference.

QuadLink™ ACL Reconstruction With the FiberTag® TightRope® SB Implant and InternalBrace™ Technique

This animation demonstrates the combined use of the Vortex™ threaded bone marrow recovery needle and the Angel® concentrated platelet-rich system (cPRP), enabling precise depth and directional control when harvesting bone marrow aspirate that can then be further concentrated through the Angel system. The Angel system’s revolutionary flexibility offers fully adjustable white blood cell content, platelet concentration, and volumes with 1- button automation from whole blood or bone marrow aspirate. Its innovative design simplifies the setup procedure and offers the capability of processing flexible blood volumes. Adaptive spin technology ensures optimal platelet recovery, while the advanced 3-sensor technology separates PRP, platelet-poor plasma (PPP), and red blood cells (RBCs) into separate sterile compartments.

Angel® cPRP System With Vortex™ Threaded Bone Marrow Recovery Needle

The combined use of the vortex threaded recovery needle and arthrex angel. See PRP system offers a precise and efficient bone marrow harvest to produce concentrated platelet rich plasma CRP from bone marrow aspirate with adjustable cellular levels to prepare for a successful bone marrow harvest. Any components coming in contact with bone marrow will need to be heparinized. Begin by filling a syringe with ten cc of heparin. Inject the heparin flush into the filter, making sure that the filter is vertical. Once the filter is fully coated, aspirate the flush back down and out of the filter. Repeat this heparin flush process with the second filter. Next, heparinize the bone marrow aspirate needle by first removing the stylet, ensuring the needle is held vertically, and injecting the heparin flush until the interior is fully coated. Remove any excess heparin, then reinsert the stylet. Finally heparinized the two 30ml back lock. Bone marrow syringes. The Arthrex vortex needle is uniquely designed with a threaded tip that allows for precise depth and directional control of the bone marrow aspiration. Typical harvest locations of bone marrow include the posterior superior iliac spine, or Sis. A target area of approximately 2.5cm around. The Sis should be used to minimize damage to the cluneal nerves. A c-arm should also be used to verify correct depth and location. It is recommended that the needle be inserted into the bone using either a twisting motion from the hand, tapping action with a mallet, or the use of a power drill connected to the needle using a power adapter or through any combination of the three. After the needle has been inserted, the stylet is removed and the vac lock syringe prefilled with four millilitres of acd-a is connected to the handle. The plunger is pulled back and rotated in a counterclockwise motion to lock into place to begin the aspiration. Bone marrow is aspirated from the ileum through the tip and the vent holes of the needle. The vortex threaded recovery needle allows for aspiration from different depths, maximizing the amount of osteoprogenitor cells recovered and minimizing the amount of whole blood obtained. Bone marrow aspirate recovered from the vortex needle can then be concentrated through the Arthrex angel system. The angel offers revolutionary flexibility with adjustable white blood cell content, platelet concentration, and volumes for a variety of formulations, from whole blood to bone marrow. This innovative design simplifies the setup procedure. Attach the heparinized bone marrow filter to the whole blood compartment. The filter will remove any particulate matter in the bone marrow. The Angel system offers flexibility in processing volumes from 40 to 180ml in a single pass. Angels simple touch screen menu and preset protocols allow for one button automation by allowing for starting volume and hematocrit level to be changed based on the desired formulation. Advanced three sensor technology separates the bone marrow concentrate and RBCs into separate sterile compartments, using cell specific wavelengths of light for consistent PRP output. Together, the Arthrex Angel system and vortex threaded recovery needle offer a precise and efficient solution to bone marrow processing.

Angel® cPRP System With Vortex™ Threaded Bone Marrow Recovery Needle

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;

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

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