Schulter

Implantate für Humerusfrakturen

Arthrex bietet mit dem Versorgungssystem für proximale Humerusfrakturen eine Komplettlösung für sämtliche Frakturklassifikationen. Das Fraktursystem umfasst: perkutane Spickung, Humeral SuturePlate™ und Univers-Frakturschaft.

Trauma Upper Extremities

Product

Das FiberTape-Cerclage-System bietet eine starke, einfache, reproduzierbare und effektive Lösung, mit der die Metallkabel und -drähte, die traditionell für die Osteosythese verwendet werden, ersetzt werden können. Der flache, breite FiberTape-Cerclage-Faden ermöglicht im Vergleich zu herkömmlichen Metallkabeln und -drähten eine hervorragende Kompression und Reißfestigkeit.1 Das System enthält FiberTape- und TigerTape-Cerclage-Fäden, verschiedene Instrumente für den Fadendurchzug, einen Fadenspanner, einen Handgriff und ein Instrumentensieb.
Referenz
1. Arthrex, Inc., Archivdaten (APT 3197). Naples, FL; 2017.

Shoulder

FiberTape® cerclage is a nonmetallic alternative to cables and wires traditionally used for fracture management during trauma and reconstruction procedures. Its high-strength, all-suture design and biomechanical properties make FiberTape cerclage an ideal adjunct for stabilization and fixation of periprosthetic femur fractures. This animation highlights the FiberTape cerclage surgical technique and how it can be used to manage periprosthetic femur fractures.

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FiberTape® Cerclage for Periprosthetic Femur Fracture

The FiberTape cerclage system is a nonmetallic alternative to metal cables and wires traditionally used for fracture management during trauma and reconstruction procedures. Its high strength, all suture design, and biomechanical properties make FiberTape cerclage an ideal adjunct for stabilization and fixation of periprosthetic femur fractures. Use a FiberTape cerclage passing hook to pass the cerclage suture and place the hook around the bone. Advance the passing hooks. Nitinol. Suture. Eyelet. Load the FiberTape cerclage. Suture. Tail into the eyelet of the passing hook, along with the tail end of a TigerLink suture. Retract the nitinol eyelet and pull the hook back around the bone and unload the sutures from the eyelet. Next, the tail of the FiberTape cerclage suture is loaded into the loop of the TigerLink. The tail of the TigerLink is then pulled to shuttle the FiberTape cerclage around the bone for a second pass. Place approximately 2cm to 3cm of the FiberTape suture. Tails into the nitinol loop attached to the loader. Separate the two tabs of the of the loader pulling the nitinol loop and the FiberTape suture tails through the knot. Once the tails are through the knot, unclip the remaining suture and remove the knot from the loader. The swaged part of the suture is then cut to separate the two limbs. The knot is then slid down to the bone. To hand, tighten the suture and remove the gross slack from the cerclage loops. Position the knot so that it does not interfere with the placement of other implants, such as plates or struck grafts. The suture limbs are then loaded into the tensioner. One limb is inserted through the bottom hole at the tip of the tensioner, and the other limb through the slot on the top. Place the tip of the tensioner down to the bone and directly on top of the knot. Wrap one suture tail at least twice around the main body of the suture wing, and then secure the tail in the cleat. Repeat this step for the second suture. Tail. Begin tensioning the FiberTape by turning the handle clockwise as tension is created. Notice the gauge lines on the back of the tensioner. Continue to apply the necessary amount of tension, making sure not to over tension. Watch the gauge lines on the back of the tensioner and do not tension beyond the fourth line. Once tension is achieved, remove the tensioner by turning the handle counterclockwise until the suture. Limbs around the suture. Wings loosen. Unwrap the suture tails from the suture. Wings. A half hitch is tied to secure the knot and aid in retaining the cerclage tension. Additional cerclage may be added if necessary. Following the same steps as previously shown after the initial tensioning is performed and the first half hitch is applied, each cerclage may be retensioned. The suture limbs are reloaded into the tensioner and the cerclage is tensioned to the desired tension. Two alternating half hitches are tied and the suture limbs are cut. After the FiberTape cerclage is used to reduce the fracture, a fracture plate may be placed directly over the FiberTape cerclage. If necessary, the FiberTape cerclage may also be used to support fixation of the plate in areas where screws cannot be placed, or where additional compression is needed to aid in stabilization and fracture healing.

Brad Parsons, MD (New York, NY), discusses the benefits of using the FiberTape® cerclage system for upper extremity applications, including midshaft humerus fractures and periprosthetic fractures.

FiberTape® Cerclage Upper Extremity Applications

I'm Brad Parsons from Mount Sinai in New York City, and today we're going to be talking about the various uses I found for the FiberTape Cerclage system. This is really provided an additional and significant help to the care of my patients in complex fracture management, even routine cases like a C separation or lateral clavicle fractures and then complex reconstructive situations. The advantage of the FiberTape cerclage system is many. It's radiolucent, so you don't see wires that break or other things that can happen. As we know with cerclage systems that are currently available, there's no sharp metal ends that are going to poke the patient's soft tissue or you while you're doing the surgery. It's easy to remove. If you have to go back for a secondary operation. You're not dealing with trying to cut wires. It's suture. So that makes it easier. It's going to provide less irritation to the soft tissues. There's no risk of metallosis if it contacts a plate or an implant. And so you don't have to worry about mismatched metals. And it's been shown biomechanically to be just as strong as braided cables. Really, for me, I think one of the biggest advantages is its very low profile, as is shown in this illustration of this fracture on the right. You can put this for both provisional fixation around fracture fragments, but it sits deep to the ultimate hardware. You may choose to put over the top of that. And so it's because it's low profile. It really adds an optimal situation to manage these injuries. I think the best way to go through this is through a series of some cases. And so this first patient is a 64 year old female right hand dominant. She sustained this fracture about nine months prior to seeing me. And she was treated initially non-operatively. But she's gone on to a symptomatic both malunion of the proximal aspect and then a nonunion of that oblique fracture distally. And so this is a complex situation. She's got really no function in her shoulder. And so we're going to try to repair this. And and so using the FiberTape Cerclage allowed me to get tremendous provisional and initial fixation in those fracture fragments. And so you can see here on these two pictures from the surgery, we're able to pass the cerclage system around the humerus. We've got a reduction forceps. And so the the suture can go right in between those two. And it gives us immediate compression and fixation of those fracture fragments in a low profile way. And so I'm able to put the the ultimate fixation over the top of that. We're able to get tremendous compression of the fracture through the tensioner. And so we know we're getting optimal bony contact and the best surface for healing in these situations. And so the final construct here you can see the plate sits over the top of the FiberTape cerclage. This patient's bone is very small. It'd be very difficult to do lag screws or other types of traditional fixation, given how small her bony fragments are. And so the FiberTape collage really made this case easier. One additional pearl and benefit, I think, in this scenario is often in these fractures the deltoid has to be released for fracture exposure or may even be torn. Same thing with the pectoralis major. I was able to use the tails of my FiberTape cerclage to repair the deltoid and the pectoralis to side to side repair, giving me both a strong bony fixation as well as ultimate and excellent soft tissue repair as well. A different example is a second patient, a young male who has this displaced type two lateral clavicle fracture. And so this is a difficult fracture to fix. There's lots of options people will try. I've used all suture repairs using coracoclavicular and inter fragmentary fixation with sutures, but that requires us to tie knots and it can be difficult to reduce the fracture. Many surgeons may try to use a locking plate for this injury, but the challenge with that is the distal or lateral fragment is quite small, and so your optimal fixation may not be as good when the fragments are so small as is shown here. I've also used the arthroscopic dogbone technique, which I think can be very attractive in these fractures and really help. But if you look at the bottom right X-ray, there's a fair, fairly significant posterior translation or separation of the fragment posteriorly. And so that concerns me about translational instability in these injuries. And so I think I want something that's going to provide even more compression to make sure we have optimal bone bone contact. So here we are Intraoperatively. We've done this through an open approach. And what I loved about this case using the FiberTape Cerclage system is I was able to pass the sutures of the FiberTape cerclage around the coracoid and around the fragment of the clavicle, and then the tensioner itself does the reduction for me, so I'm not fiddling with extra assistance trying to press on the fracture fragments and compress them. I'm not using clamps where I worry about impinging on nerve vascular structures around the coracoclavicular area. It's all superficial on the top, very safe, and the tension is so strong in the tensioning system that it gives me excellent time, zero reduction in fixation. And then we have the ability to fixate that injury very easily. I also used some suture around the fragment itself to add further cerclage fixation. So I get excellent bony compression both around the fragment as well as reduction of the clavicle down to the normal coracoclavicular orientation. So you can see here our final x ray. Excellent reduction. And the patient has gone on to heal and do very well. Another case that we had a very complex situation. This gentleman had a total shoulder arthroplasty performed approximately three years prior to his recent injury, where he fell and has this severely comminuted fracture of his proximal humerus and a periprosthetic injury. And so this can be a very difficult surgery to treat the patient for. It can be a very complex procedure. And so having the FiberTape cerclage for this injury is really optimal. And so in this case the patient's scalp was torn. And so I chose to revise him to a long stem reverse. And I'm going to show you how I did that. Having the ability to put the sutures around the distal fragments to get provisional fixation, as I showed you, for example, in that earlier case, really allows me to have excellent fixation. And then I can do additional fixation over the top like cortical struts or things if I need them. And so here's a video of this procedure. We make a long extensile deltopectoral approach. We're going to go through the soft tissues. It's important to identify the deltoid insertion distally. And often in these cases where the fracture goes down to the level of the deltoid insertion, you might have to release the anterior or even middle head of the deltoid to get exposure of the fracture fragments, obviously in a long stem reverse case where we want the deltoid to work, well, we're going to want to anatomically repair though repair that injury. And so having the FiberTape cerclage tales to do that really is an optimal situation in my opinion. So we're going to get exposure of our fracture fragments. You can see the comminution around the distal tip of the stem. And so we're going to need to manage that as well. We're going ahead and to release the the entire head of the deltoid bluntly to try to get exposure of the fracture fragments. So here we have the distal fragment exposed. We're going to do standard orthopedic care. We're going to find a radial nerve. We want to protect that when we're doing cerclage fixation around the humerus. Make sure that's not going to be entrapped or affected by our fixation. We're going to go ahead and clean our fracture fragments to be able to get an optimal bony surface for healing. And so we'll go ahead and do that with our standard orthopedic technique. We want to find the proximal segment. And then we're going to go ahead and pass our cerclage fixation around these two fragments to give me that tremendous initial fixation of the fracture fragments, to allow me to reduce it so that I can then put in my long stem implant. This low profile passer makes passing these sutures tremendously easy. It protects the soft tissues. And so we can do this in a few different levels to try to get optimal fixation of our fragments. And so we're able to do this carefully and protect those underlying nerve vascular structures. As I as I stated previously, once the sutures are passed around the fragments and we have control of them, we're going to go ahead and reduce our fracture fragments with our reduction forceps. Make sure we're happy with the orientation of the sutures. Make sure we're happy with our reduction of our fragment, and then we'll go ahead and move on to conversion to the long stem reverse implant. Once we have our implant fully positioned and seated, we can go ahead and tie our FiberTape cerclage and secure them with a tensioner. And again this gives tremendous reduction in fracture fixation. Excellent bone contact a couple of half hitches to lock the construct. And then we can use those tails to repair our deltoid and pectoralis in a side to side way. Because the patient's bony deficiency, I chose to use a cortical strut to augment bone healing in this situation. And as this was early in my use of the FiberTape cerclage, I chose to use wires in this situation because I was concerned about fraying around the cortical strut. The reality is, I've learned from colleagues like Brian Cohen and others who have used this routinely with cortical struts. Really, the FiberTape cerclage gives optimal fixation of those constructs as well, and there's been no issues with fraying or damage. And so I really don't think you need to use wires like we did in this case. So this is our final construct As you can see, utilizing a 135 implant with a long stem, we get an anatomic reduction of the tuberosity around the implant. We have optimal position of our fracture fragments and an anatomic reduction distally. And I was able to restore soft tissue tension utilizing the modular glenoid system with a laterally based base plate and sphere to give perfect restoration of cuff tension and function. So, in conclusion, I think really one of the things that the FiberTape Cerclage system offers to me is the versatility. We need to handle a complex spectrum of different injuries in our patients. It allows us to treat fractures of the humeral shaft, femoral shaft with cerclage techniques. It's low profile. We can still use additional fixation over the top. I've used it now for tuberosity repairs around a reverse implant and proximal humerus fractures. And it allows us for these complex situations, like a periprosthetic fracture where we can't use conventional hardware like screws and optimal ability to fixate the fracture around our implant. So we have a stable construct that we know is going to go on to heal and do well for our patients. Thank you.

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FiberTape® Cerclage System - Single-Use Instrumentation

John David Adams Jr, MD (Greenville, SC), demonstrates how to apply FiberTape® cerclage for lower extremity fracture management. Dr. Adams highlights the use of novel, single-use cerclage instrumentation, including a disposable passing hook and tensioner.

FiberTape® Cerclage Disposable Instrumentation for Lower Extremity Fracture Management

I've found that one feature of the Cerclage parser that's really nice is the beveled tip, and that has a tendency to allow you to pierce through that dense tissue in the posterior aspect of the femur pretty easily. And so my typical technique is to go over to the anterior aspect of the femur, hug close to bone, and then as I pass over the the femur, staying close, and then rotate my hand and eventually piercing through that fascia in a similar fashion here. And so once I've done that, we get to take advantage of a particular feature that's unique to this disposable system that I want to show here, which is the nitinol wire that comes out the end of the parser. And this is a really neat feature that traditionally you have to find the end of the parser and then be able to pass the FiberTape cerclage through that small islet. And the nitinol loop is really unique in the sense that it brings it up more into the field, and it also gives you a loop that's much easier to pass the FiberTape Cerclage. And then once I'm around the femur, I advance the nitinol loop and then I can start passing my FiberTape Cerclage. And so now the FiberTape cerclage comes on this loader. I'll just unwrap it here. And I'll set that to the side. And then I'll bring the FiberLink as well. So we'll pass both of those. And one nice thing about this nitinol loop is it's much easier to pass this through. So once we pass both of those through now I can pull the nitinol loop back into the disposable passer, and that will secure both sutures and then bring it around the femur. So now that I've brought it around the femur, I will just deploy the nitinol loop again to release that. So once I'm ready to pass the FiberTape cerclage through the FiberLink. It goes through the loop, and then I'll grab the FiberLink and that will facilitate the second pass. Fiberlink goes to the side. Now you can grab the rest of the FiberTape Cerclage. And now we have a double loop. So it's very easy from here to now. Load the FiberTape Cerclage. Pass this through the nitinol loop of the of the loader, and then that pulls the FiberTape cerclage through the. The locking mechanism. Once that's through, you just slide this knot off the loader. Now that I've pulled the racking hitch off the loader. The loader can now be put off to the side. And essentially everything brought back down to the femur. So now that I've got that down, the next thing that we're going to do is begin to tension. So we'll take that swedge portion, cut the swedge portion off and then be able to load the tensioner. We're now ready to begin the tensioning process with the now new disposable tensioning device. The first thing you'll notice is there's two slots at the end of the tensioner. We'll place one end of the cerclage tape through the hole of the tensioner, and this can now be reduced down to that racking hitch. The other end is going to be passed through the other slot of the end of the tensioner. Now once I've done that, I'm going to pass one of the ends around the tensioner At least once and then cleat it. Now I'm going to take the other end and pass it around the other side of the tensioner and then through the cleats. And so that has now secured both ends of the FiberTape cerclage. Now it's very easy to tension. It's just the ease of just twisting this knob. And I'm going to show as this tension as I squeeze it. It's going to tension this down. And then also to get an idea of how much tension there's lines on the back end of the tensioner. I'm showing two lines here. There's a total of four. You do not want to go past four. I typically go around three. Seems to be providing the amount of tension that I want. So we'll take it. Take it down to three. The way this works is there's 100 pound spring inside that is using this to counter force and be able to give the amount of tension. So once I've done that first tensioning now I'm going to release that tension. I'm going to unclip both sides. I don't have to take this end out of the Of the tensioner and I'm going to throw my first half hitch. I'm going to reduce this down to the FiberTape cerclage and then tension that knot once more. So repeating that same process and now the tensioner most likely is not going to be able to go all the way to the third line again, because I'm just taking residual slack out. And so it is getting pretty tight right here at one. I'm starting to get to two, and I feel like that's about as tight as I can get it. So now that I've done that, I'm going to release the tension that should have now locked the tension in place. I'm going to unload the tensioner, and then it's recommended to actually change post now and switch that and reverse post. And then now that can be cut. So now as you can see now that this is tension, this is very tight and it provides very good circumferential compression around the femur.

Matthew A. Varacallo, MD (DuBois, PA), discusses using FiberTape® cerclage for fracture management in the upper and lower extremities, including fractures of the periprosthetic femur, transverse patella, and clavicle.

Upper and Lower Extremity Fracture Management With FiberTape® Cerclage

Hello, my name is Doctor Matthew Barrichello from Penn Highlands Health Care System in Dubois, Pennsylvania. So today I'm going to be talking about the Arthrex, FiberTape Cerclage and its various applications throughout the body in various anatomical regions. So this first case here is a periprosthetic femur fracture. This is a gentleman 65 years old, and he's a very large gentleman, as you can see, by his BMIs over 40, and he weighs about 300 pounds. So after he had his index total hip procedure, he unfortunately fell and sustained this. On the right you can see a displaced lesser fracture periprosthetic femur fracture. His acetabular component is still in good position, obviously, but his stem has subsided. So you've got to take him back and fix this. And so I'm going to show a series of images here. This first one is the provisional reduction. And the nice thing about the Arthrex FiberTape Cerclage is that when you're placing this around the bone, you still have the ability to radiographically evaluate your reduction. So here you can see I have the clamps in place. It's pretty good, but we can get it a lot better. So I actually took the first two out at this time frame. And then I got a much better reduction again. I used about seven of these in this case. This fracture line extended pretty distal and I was able to get an anatomic reduction. Here I have the trial brooch in place. And the other nice point about this construct is that you have the ability to retension multiple times. So I have the brooch in place here. I actually retensioned after that. And then I was able to retension again with the final stem that's in place. You can see this fracture on the left is not even visible with this. So again, this construct, as opposed to having cables in the way you can see, get a nice transparent evaluation. This is the prior to the final reduction with the implant in place. And then if you look at this guy's x rays from three months out, you can't even tell that he ever fractured. So that's that's the goal. And he's actually back to all activity at this point. This is probably my favorite case of the series. Talking about patella orif without hardware. That's always been kind of the holy grail. Whenever you're fixing the patella, there's the inherent risk of post-traumatic arthritis, which we can't really change. But the point I want to highlight here is the intra-articular damage that can happen to the patellofemoral compartment. It just so happened very recently, I did a case where a patient was referred to me, had significant hardware breakage that required the removal. And you obviously have the wire migration that occurs when the patient is doing motion. So this was the case. And you can kind of tell, especially on the axial view of how that hardware has essentially gouged into this patient's lateral trochlea. It's really unfortunate. So I took her back. And these are the shots. And this is what can happen especially when you have the hardware in place. So I started using the all suture technique because I do a lot of joint reconstructions. And the case that I'm going to show is a potential future total knee patient. And you want to think about having to the less amount of hardware that you have to remove, the better in this situation. Obviously here with this patient causing significant damage to the joint, she now needs a total. So the case you have a transverse displaced patella fracture and this patient is 55 fell directly onto her left knee. No significant past medical history. She's an She's an active gardener, walks daily. She's, you know, recreationally pretty active, unable to straight leg raise on exam. Got a CT and the CT measuring it was about 2.3mm displaced on the articular side. So given that and also the fact that she was unable to perform a straight leg raise led to operative fixation, and I was talking to her about potentially doing an all suture option. So this, again, in my mind, is the holy grail with utilizing this. And, you know, if you can avoid using the hardware. So just like any other orthopedic procedure, when you're dealing with a fracture, the same sequence applies. You get your reduction, put the pins in the trajectory that you need them across the fracture pattern, and then you over drill with the cannulated drill bit and then what you want to do. And I unfortunately don't have a video of me doing this, but you keep the card on either the superior left corner or the inferior on the right side. So either super immediately or or infero laterally. Anatomically is where you want to have that card, and then you're passing the free end in a figure of eight construct to get that that tension band fixation. And you reduce tension it back when you're feeding it through the through the tensioner at the site where you started that first pass. So I just have the live intraoperative images here again pinning it. And you can see there's multiple wires here because the first time I passed it I wasn't satisfied with my trajectory. So I changed that. And then you can see the reduction. And this is the best part is you look afterwards. So the initial fracture pattern on the left again unable to do a straight leg raise. You see the displacement which is better appreciated on the CT. And then her x rays at three and a half months on the right where you can't even tell that she ever fractured it. And the interesting part if you're like me, you like tricking the radiologist where they're saying no fracture normal knee radiographic series. And that's that's probably one of the the most rewarding parts about it. Here she is at two and a half months with good motion. And she's doing a straight leg raise here in the office. But again highlighting her her knee again this was read as a normal knee series. So the radiologist couldn't even tell that there was there was ever a fracture. So you compare this patient to the patient that had the wires that were breaking and damaging the joint. This lady maybe at some point needs a total. You can see she has tri compartmental. Oh, but right now her function is excellent. And here she was a few weeks after that visit. She's walking for me. And then she was just like, oh, can I jog right now? She took no narcotics after surgery. I showed you her accelerated recovery timeline as well. And she has zero knee pain. And she had zero knee pain the entire time after surgery. So that was that's the difference from having the hardware in place versus doing it with the all suture technique. Here's another interesting case. This is the last case set here. This is a 30 year old male right hand dominant laborer. And when I say laborer he has to carry about 200 plus pounds over his operative side, the shoulder. And so he had about two weeks where he was treated non-operatively. And he continued to have a lot of pain and dysfunction and a lot of concern and anxiety with his work considerations and return to work. So I had a very frank discussion with him. I said, hey, in your line of work, if I'm putting a plate in 100% chance, it's essentially going to need to come out. And so I talked to talked to him about doing an all suture fixation. So you can see here's the reduction. And so there's the final construct. Here's the best part. So he comes again. He took no narcotics or opioids post-op. He had full motion by four weeks. He was able to do three three sets of ten push ups by three months. So here he is in the office. He just said, hey, can I get down and show you something? So he was doing these push ups by three months. So obviously he's feeling pretty good and he had zero pain. He actually commented to me multiple times, did you even do surgery on my shoulder? And here's the best part right there. So you can see his post-operative x ray. It's like he never fractured his clavicle, which is great. I mean, you talk about this is a case where 99.999% of the time you're taking this plate out, and because you could fix it with this outside the box, all suture fixation principles, you save this patient a second surgery, and he's able to return to work quicker. And he doesn't need that second operation. So here's his final series. Here you can see the displacement. And those are his x rays at four months. Thank you.

Brian Spencer, DO (State College, PA), discusses using FiberTape® cerclage for proximal femur fractures. The high-strength, broad footprint compression of FiberTape cerclage make it the ideal alternative to metal cables.&nbsp;

FiberTape® Cerclage Fixation of Periprosthetic Hip Fractures

I'm Doctor Brian Spencer from State College, Pennsylvania, and today I wanted to share with you some of my initial experience using FiberTape Cerclage for fixation of periprosthetic hip fractures. Some of the advantages that I found of all suture cerclage over the traditional braided cerclage is that there's no sharp wire ends and less irritation to the surrounding soft tissues. With the all suture cerclage compared to the braided wires, there's better contour to the bone, especially in the proximal femur with the better contour to the bone. There is better distribution of forces, and there's going to be less micro motion at the fracture site. And also it's going to be less gapping between the bone and the cable. There's no need to worry about migration of cables around the femoral neck. You can place the cerclage through the iliopsoas tendon on the lesser trochanter. I don't need to worry about the placement of the crimpers. That really opens up my surgical field, especially if I'm going to do any plate fixation. I don't have any crimpers in my way or any crimpers to crimpers to worry about with provisional fixation. Using the all suture cerclage, the plate sits flat directly on the sutures, and another big advantage is I don't have to worry about the exact placement of my cables, because if I want to place a screw through my plate and there's a cable in the way, if it's an all suture cable, I can drill right through the suture and still get the screw fixation that I want. So let's look at some cases. The first case is a 76 year old female who fell in her driveway. She presented to my hospital with this periprosthetic proximal femur fracture. This was my initial experience using the FiberTape cerclage. The fracture did propagate distally. So for this case, I did use standard traditional braided cables distally to prevent any further fracture migration, but I wanted to use the FiberTape cerclage more proximally. I feel that because it contours much better around the bone and there's less gapping, I feel it's better fixation for areas of the proximal femur, especially around the lesser trochanter. So I placed one cable proximal to the lesser trochanter. One distal to it and one through the iliopsoas tendon. This is post-op films three months out. As you can see, the lesser trochanteric fragment has healed completely. There is no gapping, there is no displacement, and the fixation seemed to hold well and the patient is doing very well. The next case that came in is a 59 year old female who fell in the shower. I was a little bit more comfortable using the FiberTape cerclage at this point, so I used the FiberTape cerclage for my provisional fixation just distal to the fracture fragment. I placed FiberTape cerclage to prevent any further fracture propagation. I then placed the fitting stem and then I placed three FiberTape cerclage proximally one superior to the lesser trochanter, one inferior to it, and one through the iliopsoas tendon. These are her x rays. Six months post-operatively I was able to get excellent fixation of the fracture. As you can see, there's absolutely no displacement of the lesser trochanteric fracture. She's been up and walking around and she is back to full activities without any irritation or any complications. This next patient is an 82 year old female who presented to the hospital with a native hip infection after receiving multiple intra-articular injections into her left hip. Because of the destruction of the femoral head, I decided to remove the femoral head and treat her with an irrigation as well as a cement spacer. I also treat her with antibiotics and four months afterwards she was up and walking with a walker and she felt a crack in her left hip. She came back to the hospital and these x rays showed a left periprosthetic femur fracture. Fortunately, all the lab studies had shown that the infection had cleared. So I was able to convert her to a standard total hip arthroplasty, as in the other cases I used. Fibertape cerclage distal to the fracture to prevent any further fracture propagation. I then placed three FiberTape cerclage through the lesser trochanteric fragment to fixate the lesser trochanter back to the proximal femur. She's done well. Post-operatively and the infection has not returned. Now, with this case, in retrospect, because it was poor CeMend technique on purpose, and because she had very poor bone quality, I possibly could have done provisional fixation with a FiberTape cerclage during the index procedure. However, at the time I was a little bit more worried about clearing the infection. That brings me to my last case, which is the 61 year old female who presented with a displaced femoral neck fracture. She did have advanced arthritis of her left hip and given her young age, we decided to do a left total hip arthroplasty because of her younger age. I wanted to use a press fit prosthesis. I did not want to use a cemented stem in this case, and also because it was a fracture. I'm always concerned about bone quality and I'm concerned about further fracture propagation. So in this case, I wanted to do a simple FiberTape cerclage at the end of the case to help prevent any fractures or periprosthetic fractures in the future. This is done through a standard anterior approach. I pass passed the parser around the proximal femur, just superior to the lesser trochanter. I put the FiberTape cerclage and a FiberLink through the eyelet and passed it back around. I then used the FiberLink to pass the FiberTape cerclage around the proximal femur a second time. I placed the tails through the loading device and was able to push the sliding not directly down onto the proximal femur. I then placed the tails through the tensioner and was able to tension the FiberTape appropriately. I then did another half hitch and retention the fiber tapes. I then placed two half hitches at the end and then cut the sutures. The total time it took me to do the provisional fixation at the end of the case was about 8 to 10 minutes. And with this, I now worry less about any irritation of the soft tissues or any cable migration than I would if I did. Traditional braided cable fixation. Also, with the provisional fixation, I can also. Worry less about any periprosthetic femur fractures in the future. So in conclusion, the FiberTape cerclage has been found to be just as strong as the braided cable. The FiberTape cerclage, I find, is more advantageous for provisional fixation of a fracture. Also, as I showed in these case studies today, especially advantageous for fracture fixation of the lesser trochanter, it contours very well against the lesser trochanter with minimal gapping. And as I've shown on my follow up films, there's really no displacement of the fracture. It's also good for prophylactic fixation of the proximal femur in a total hip, and with using it as the provisional fixation. I worry less about soft tissue irritation or migration of the cables in the future. Thank you.

FiberTape® Cerclage Tension Band System

FiberTape®-Cerclage

Child (D)

Trauma Lower Extremities

Das Humerus-Nagelsystem von Arthrex bietet 2&nbsp;spezifische Optionen für das Nageln des Humerus. Der kurze Nagel ist für eine schnelle und effiziente Behandlung von Frakturen des proximalen Humerusdrittels konzipiert und weist eine selbstbohrende Trokarspitze zur weiteren Verkürzung der Operationsdauer sowie 4 proximale Schraubenoptionen auf. Der lange Nagel ist mit 3 proximalen Schraubenoptionen und in Durchmessern von 7, 8 und 9&nbsp;mm mit Längen von 20 bis 30&nbsp;cm erhältlich. Durch eine interne Kompressionsschraube im langen Nagel wird die Reposition und Kompression der Fraktur unterstützt. Jeder Nagel enthält Schrauben, die in den Nagel eingeschraubt werden. Dadurch wird ein Zurückdrehen der Schrauben verhindert und ein winkelstabiles Konstrukt für zusätzliche Stabilität geschaffen. Das vereinfachte Instrumentarium trägt zu einem effizienten und reproduzierbaren Verfahren bei.

Arthroplasty Shoulder

Humeral Nail System

Humerus-Nagelsystem

Das Humerus-Plattensystem von Arthrex ist eine umfassende Lösung für das Management proximaler Humerusfrakturen. Drei Plattenoptionen beinhalten eine 95° größere Tuberositas-Abstützplatte, eine 130° PHP zur Begrenzung des subacromialen Impingements und die anatomisch geformte ALPHA-Platte zum Erhalt des Deltoideus-Ansatzpunkts. Alle Platten nehmen 4.0 winkelstabile Schrauben mit Teil- und Vollgewinde und 3.5 winkelstabile und nicht winkelstabile Schrauben distal im Schaft auf. Farbkodierte Instrumente und ein vereinfachtes Sieb-Layout ermöglichen eine schnelle und wiederholbare Fixierung aller Frakturtypen.

Proximal Humerus Plating System

The Proximal Humerus Plating System provides three distinct plate offerings for treating a variety of fracture patterns. The ALPHA plate incorporates side-specific anatomic contours that helps spare the deltoid attachment site and a crossing screw pattern proximally. The system also features the 95° greater tuberosity buttress plate and the 130° PHP for limiting subacromial impingement.

The Arthrex proximal humerus plating system is intended to treat a variety of fractures of the proximal humerus. The system features the alpha anatomic plate, 95 degree buttress plate, and the 130 degree proximal humeral plate. The alpha plate is a unique, site specific, anatomically designed option featuring crossing screws for increased screw length in the humeral head, suture holes for cuff repair, a choice of 4.0mm fully or partially threaded, locking screws proximally, and interior bend to avoid the deltoid insertion site, an oblong hole that allows up to five millimeters of compression and accepts 3.5mm locking or non-locking screws in the shaft. The blue and yellow color coded screw configurations can be used interchangeably proximally, while the green and gray screws are interchangeable distally. Begin the procedure by positioning the plate on the bone with the alignment guide attached. Using the 2.8mm multiple drill guide, drill bicortical through the slotted hole with the 2.8mm calibrated drill bit. Using the laser markings on the drill to determine screw length, insert a non-locking screw through the hole using a t15 driver and handle. Verify the proximal screw trajectory by inserting K-wires through the aiming block and verifying using fluoroscopy. Insert the screw sheath into the alignment guide followed by the 3.5mm drill guide. Advance the 3.5mm step. Drill through the sleeve until the drill tip reaches subchondral bone. Unthread and remove the drill guide from the sleeve using the depth guide. Measure to determine the desired screw length to be inserted. Insert a 4.0mm partially threaded locking screw through the sleeve. Repeat the steps for the for the remaining proximal screws. The choice of fully or partially threaded 4.0mm screws is based on surgeon preference. Once all proximal screws are inserted, remove the alignment guide for the distal holes. Begin by threading the 2.8mm locking drill tower into the screw hole. Drill bicortical using the 2.8mm drill, and use the calibration lines on the drill bit to determine screw depth. Unthread and remove the locking drill tower and insert a 3.5mm locking screw using the hex driver. Repeat the previous steps to fill the remaining holes with 3.5mm screws to complete the plate. Fixation SutureLasso technology allows for repair of the rotator cuff to the plate after the plate is applied.

Charles J. Jordan, MD (Miami, FL), demonstrates the surgical technique for the ALPHA plate, the 95° plate, and the 130° plate.

ALPHA Proximal Humeral Plate System Operative Technique

So today we're going to talk about the proximal humerus plating system. I think you'll notice that this is a very comprehensive system. It's probably as comprehensive as you'll ever need for any solution. There's three basic categories of plate. One is a straight plate with 95 degree screws approximately. Another one is a straight plate as well with 130 degree screws. And then there's the alpha plate, which has variable angles to each of the screws as far as inclination and trajectory, as well as dedicated bends in order to adapt the plate to the anatomy of the humerus. So we'll start off by talking about the 95 degree plate. I tend to choose this plate when I want the plate to sit a little bit higher, i.e. when there's a large greater tuberosity fragment, the proximal portion of the screws have a 95 degree trajectory, and that allows for a longer profile from superior to inferior. You'll notice that there are five proximal options, the screws of which run at 95 degree trajectories. And then there's two there's two calcar options below. This makes for a longer profile from superior to inferior, and allows a little bit more superior positioning of the plate. I tend to choose this type of plate when fixing fractures that involve primarily a large greater tuberosity component. In order to be able to buttress the tuberosity and avoid superior migration. Next is the straight 130 degree plate. You'll see that because it sits a little bit lower on the humerus, the profile from superior to inferior both tapers down and is a little bit shorter in length. I think that ideal indications for this plate include simple two part fractures, fractures in which the surgical neck is the primary fracture line. And in a situation where I'm going to use a deltoid splitting approach for those who prefer a straight plate option, even in extensile fractures, there's a 14 hole option as well. This plate sits on the lateral border of the humerus all the way down. And finally there's the alpha plate. The alpha plate was designed originally with complex and extensile fractures in mind. As you can see, as one extends down into the humerus, the plate has an anterior bend in order to avoid the deltoid insertion, and then has a secondary bend with a twist in order to become essentially an anterolateral humeral shaft plate. The screw trajectories in all three plates are very different. Like I previously mentioned, the 95 degree plate is intended to provide a solution for situations in which you need a plate that sits further superior and creates essentially a 95 degree fixed angle construct. Whereas the 130 degree plate essentially creates the so-called hat on a hook construct, which helps to neutralize various stresses. The 95 degree and 130 degree plates have a diverging screw pattern, whereas the alpha plate screws converge. There's a couple of reasons for this. Number one, as the screws converge, the point at which they all converge creates an intramedullary point of resistance, or an intramedullary strut that allows the blockage or the prevention of subsidence and settling of settling of the humeral head, especially in comminuted fracture patterns. Also, the paths in this converging design tends to create for longer screws and more threads in bone. And finally, this converging pattern also creates a construct in which each screw is a Czech grain to the screw above it to resist any varus displacement or various failure. The instrumentation for the set is very straightforward. Each plate comes with its own targeting block that fits the superior portion of the plate, and they allow for ease in insertion of the locking towers. This becomes especially important with the alpha plate because of the convergent pattern of the screws. Sometimes it can be a little more difficult to thread the locking towers onto the plate without the use of the guide. Okay, so just to mention about the deltoid split. One thing that's important to remember is that the deltoid splitting approach starts at the anterolateral border of the acromion and extends distally. You have about 4 or 5cm worth of area to work with here before you enter the window where you need to avoid the axillary nerve. You can always extend the incision beyond that, but generally you work in two windows. Today we're going to be focusing mostly on the deltopectoral approach, because this tends to be the workhorse approach for the majority of fractures, especially with complex fractures. So I'm just feeling for the coracoid process. And my incision tends to start just lateral to the point of the coracoid process and extends longitudinally and laterally along the deltopectoral interval and down towards where my anterolateral approach would be for the humerus. The anterolateral approach to the humerus, which is the natural extension of the deltopectoral approach, tends to go along the anterolateral border just lateral to the belly of the biceps. So we're going to make a skin incision. Along the deltopectoral interval. And it's going to extend down to the anterolateral approach for the humeral shaft. Today we're going to going to implant one of the longer alpha plates, just so I can show you as many of the features as possible with regards to the design of this plate, especially as you extend into more complex fracture patterns and into more distal fractures. So the first major landmark that we look for is the cephalic vein. And here, although with this specimen, for obvious reasons, the vein is very collapsed and may not be as straightforward to find. It tends to be a very large landmark that really points out the deltopectoral interval. So I'll deepen my retractor a little bit here and actually put it into the deltoid muscle laterally, just in order to be able to bring the vein further into my field of view. This is basically the space between the deltoid and the pec. And now we've started to develop the interval here. And as we develop this interval you can start to see the border of the deltoid and the sub deltoid space, which I'll usually develop bluntly. And the pec major. I'll usually put in a deltoid retractor. Retract back the deltoid. Now you can really visualize the proximal humerus, the lateral border of the proximal humerus, and the biceps tuberosity. Depending on the fracture and depending on the amount of exposure needed. I'll sometimes take down a portion of the pec insertion, but it's not always necessary. And a retractor is often useful once you've developed the space underneath the coracobrachialis. So the bicipital groove runs right in between the greater and lesser tuberosity. And that's generally a huge landmark for the placement of this plate. We're going to dissect distally now. So as I complete my dissection here let me point out some anatomic landmarks for clarity. The deltoid is sitting behind this retractor. Here's the strap muscles, the coracobrachialis tendon, and the pec major insertion. We're looking here at the biceps muscle belly and deep to the biceps. Muscle is brachialis and just distal is brachioradialis. Distally, we retract medially, the biceps muscle belly always keeping in mind that the musculocutaneous nerve and neurovascular bundle are deep to biceps and slightly medial. This entire portion here of the humerus represents the entirety of the deltoid insertion. It's a big, long, broad insertion and just distal to where the deltoid insertion ends. We split brachialis at the lateral one third medial two third junction, taking advantage of its dual innervation. Okay. So here's the deep dissection. And like I showed you before here's the pec insertion I've basically only taken down about a centimeter of it. It's all completely intact. We've now reflected brachialis off of the humerus. And as we come down to Brachioradialis, we've also dissected out and found the radial nerve. So, as you already know, the radial nerve courses posteriorly along the spiral groove and then emerges approximately 10 to 14cm proximal to the lateral epicondyle of the humerus. And you generally tend to find it in the lateral border of your surgical field inside the brachioradialis musculature. Before I retract or reflect any portion of the deltoid, let me point it out to you just inferior to this retractor. We're basically reaching the bottom of the sub deltoid space. And this is the entirety of the insertion of the deltoid. Now as well, you'll see that as we release it and retract it further. It's also a very broad insertion that takes up almost the entire lateral cortex when placing an alpha plate. The block that guides your locking towers has a little peg on it that mates with the plate and allows you to find the right position for it. Next you screw on the guide. And then I'll oftentimes put the inferior most locking sleeve in. So remember there's two sleeves. There's an outer sleeve and then there's the inner locking tower. And the purpose of that is to be able to have a guide for your screw trajectory, even when you remove the locking tower. And I'll use this as my guide in order to determine the height of my plate. Okay. So when placing the plate, I'll oftentimes if I have this entire surgical field dissected, I'll retract the radial nerve, slide my plate down inferiorly, and then place it basically using the superior portion of the plate behind the deltoid into the sub deltoid space. And generally you can feel a feel a natural spot where it belongs. Lateral to the pec. Insertion. Medial to the deltoid. Insertion and distally. Almost directly anterior on the humerus. I've placed my plate directly underneath the deltoid and just medial to the deltoid insertion. You can see that the first anterior bend of the plate completely avoids the proximal portion of the deltoid insertion. The second bend basically creates an anterolateral plate that allows you to plate all the way down the humerus. Being able to avoid all of the lateral soft tissues, including the radial nerve, which I'll show you once again. Besides the deltoid insertion and the pec major insertion, the most important bony landmark is the bicipital groove. In this specimen, we haven't dissected off the soft tissues to show the bicipital groove, but the lateral border of the groove can be palpated quite easily, and by placing the inferior stem of the plate up against the lateral portion of the bicipital groove, you're usually able to find your spot along the proximal humerus and therefore along the sub deltoid space fairly easily. Additionally, that's where the contour of the plate kind of allows the plate to sit right where it's supposed to go. Once we found this sweet spot, so to speak, of the plate, I'll generally shoot a wire in the inferior most hole of the proximal segment, and I'll shoot a K-wires in and take an x ray and make sure that that trajectory of the wire is aiming right at the calcar, or the inferior most bone of the surgical neck. After we get our wire in and we're confident that the height of our plate is correct, this is where I fine tune my reduction. You may have already at this point used some traction, some manual manipulation, maybe even some K-wires peripherally. I'll oftentimes use a large pointed reduction clamp skirt underneath the strap muscles and through the subscapular in order to be able to adjust my position of the humeral head relative to the plate. A lot of times I'll use this K-wires hole and actually either twist and give myself more valgus, or even just give myself more compression, or rotate and give myself more apex anterior or apex posterior angulation. So I use this in order to get my reduction. And then I'll go ahead and finish my fixation. In this case, I've fine tuned my reduction and used one of the superior suture holes as a counterpoint in order to be able to reduce my fracture. And at that point, we'll hold the reduction using some K-wires. You'll see that there's K-wires holes Along the proximal guide block. As well as outside the block. Once you've gotten your proximal reduction, depending on the fracture pattern, you can either complete the fixation proximally or distally. Oftentimes, I'll come back down distally and use another reduction clamp in order to ensure that my positioning distally is correct. Distally, you may or may not choose to use a reduction forceps in order to fine tune the positioning of the plate if necessary. But in general it should sit well. Medial and anterior to the radial nerve. So now we're going to start completing our fixation. And I'm using the blue locking towers which have these outer sheaths as well. And everything is color coded. I'm using the blue locking towers in order in order to place the four fully threaded screws proximally. So in this case, we're going to put in 4.0 cancellous fully threaded locking screws there. The blue screws, which means you're going to use the blue tower and the blue drill. The drills are calibrated. So you're usually able to tell your screw length off of the drill. However, there's also a depth probe that can be used, which is a blunt tipped device that inserts into the sheath. And we'll also give you a depth measurement. It's blunt, so you can place it up against subchondral bone and get an accurate measurement. After getting a couple of points of fixation, usually 2 to 3 screws, I like to start pulling K-wires out in order to give myself more room to complete the fixation. And generally, at this point, what I'll do is I'll remove the k wire that's through the tower and go ahead and drill for that screw. There's a laser line on the screwdriver shaft that I use as a guide to know when I'm about to lock into the plate, and that's the point at which I use a hand screwdriver in order to final tighten. We're also going to demonstrate the use of the gold screws. They are for a partially threaded screws. I tend to use them when I want a little bit of a larger caliber screw. We'll use the yellow locking tower and the yellow drill. So one other thing that I wanted to show you about the positioning of the plate. The biceps tendon is right here. And this is just medial to the proximal border of the plate. So this is another guide that you may want to use to guide your positioning. So here we're using the 3.5 conical or stepped drill once again in order to place another four partially threaded screw. Once you've got enough points of fixation in, you can also internally rotate the arm without losing your reduction, and it'll make it much easier to work without having to fight the deltoid consistently. So I pass my drill across the fracture to the point where I feel subchondral bone. So at this point, presumably any extensions into the shaft are reduced and fixed as well. You may even choose to put some lag screws in. I happen to have a clamp holding my plate in place, but if you feel more comfortable, you can use any of the K-wires holes that go along the plate. And we're just going to use a couple of non-locking and a couple of locking screws to finish our fixation distally. So there's two options. There's a locking tower and there's also a handheld soft tissue Protector. And there's two sides. One is for non locking screws and one is one is for locking screws. The locking screw side conforms to the hole and allows you to drill at the nominal angle. The non locking side allows you to vary your angle and for non locking screws. I like to use this guide because it allows me to change my angle, especially because this is a plate that changes angles itself. It allows me to be able to shoot into the shaft at whatever angle I want. The non locking screws are gray and the locking screws for the shaft are green. At this point we've completed our proximal fixation and removed our aiming block. You'll notice that there are oblong holes along the curvatures of the plate. And you can use these for a couple of different uses. Number one, if there's a situation in which you want to fix the plate to the humerus first through an oblong hole and then fine tune the position of the plate. That's a very good use for that. Additionally, you'll notice that the oblong holes themselves, at their superior and inferior extents have threads in order to insert locking screws. In this example, we've put a locking tower into one of the oblong holes at the inferior most extent, and I'm placing a locking screw. These are green. Here we've placed locking towers along the shaft and the drill bit is calibrated, which will allow me to quickly measure and place the last few screws. So to recap, we have a retractor in. But essentially the proximal portion of the plate goes laterally right over the deltoid. The entirety of the deltoid insertion remained intact as our plate curves anteriorly. To avoid the deltoid insertion medially, you have the pec major insertion, as well as the biceps tendon, and distally we're anterior on the humerus, and this allows us to avoid the not only the deltoid insertion, but stripping of all the lateral soft tissues and involvement of the radial nerve in the surgical field. When deciding on plate height and plate position, it's much more reliable to go with relative position to where the calcar screw is going to go, rather than where the plate is going to sit relative to the greater tuberosity, which can be a lot more variable with regards to positioning of 130 degree straight plate proximally, it's very similar to the alpha plate and any other proximal humerus plate, with exception to the fact that you'll often have to take down a little bit of the deltoid in order to be able to get it at a proper lateral position. So if necessary, you may need to release a little bit of the deltoid. You'll notice that I've released a small amount of deltoid in order to place the plate, and there's also a locking screw in the inferior most hole of the proximal segment. And that's in order to use the calcar Corkscrew as a reference for plate positioning, and not necessarily the position of the greater tuberosity. For me, the 95 degree plate is really a plate, used mostly when I have a fracture pattern that involves a large greater tuberosity fragment because of the trajectory of the screws. I can place my plate as superiorly as I want with relation to the greater tuberosity. Knowing that I'll get screws into the head and not superior to it. Now the alpha plate comes in variable lengths, and the purpose of its anterior bend, even with a short plate, is such that there's no removal of the deltoid necessary and no release of the deltoid insertion. So even when using it for a proximal humerus fracture that doesn't require a long plate, the positioning is very similar to that of a long plate with regards to its position proximally, and the use of a locking tower in one of the holes in order to judge positioning.

Humerus-Plattensystem

Bei der Humeral SuturePlate handelt es sich um eine anatomisch geformte polyaxial winkelstabile Platte und ein Schraubensystem zur Versorgung von proximalen Humerusfrakturen. Diese flachen Platten mit polyaxialen Lagerschalen (Bushings) ermöglichen eine bessere Fixierung der Verriegelungsschrauben durch eine anatomische Anpassung der Schraubenausrichtung an den Frakturtyp und die Knochenqualität. Mehrere angeschrägte Fadenöhre entlang dem Plattenrand ermöglichen den Durchzug eines FiberWire®-Fadens nach Fixierung der Platte am Knochen. FiberWire-Nahtsets mit farbcodierten FiberWire-Fäden der Stärke #2 oder #5 mit Nadeln an beiden Enden erleichtern das Annähen von Weichteilgewebe an die Platte nach der Platzierung.

Humeral SuturePlate™

Das System zur perkutanen Rekonstruktion von Humerusfrakturen enthält alle erforderlichen Instrumente und Implantate, die für die perkutane Reposition und Fixierung von 2-, 3- und 4-Fragment-Frakturen des proximalen Humerus mit 2.8 mm Pins und kanülierten 4.5 mm Schrauben erforderlich sind.

Implantate für Humerusfrakturen

FiberTape®-Cerclage

Humerus-Nagelsystem

Humerus-Plattensystem

Humeral SuturePlate™

Perkutane Spickung