Trauma Lower Extremities

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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.

Trauma Upper Extremities

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Proximal Humerus Plating System

Arthroplasty Shoulder

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.

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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

Child (D)

Das Klavikulaplatten- und -schraubensystem ist ein umfangreiches Set an Platten, Schrauben und Instrumenten zur Versorgung von medialen und distalen Klavikulafrakturen. Die vorkonturierten Edelstahlplatten zeichnen sich durch ein flaches Profil aus und können mit winkelstabilen oder nicht winkelstabilen Schrauben verwendet werden. Eine sekundäre Fixierung am Korakoid wird durch die Kombination der Platte mit der AC-TightRope-Implantat-Technologie – insbesondere mit dem AC Dog Bone-Button – erreicht.
Das knotenlose distale Klavikula-TightRope-Implantat mit Klavikulaplatten-Button ist für den Einsatz mit jeder beliebigen distalen Klavikulaplatte von Arthrex konzipiert und ermöglicht dem Operateur eine knotenlose Korakoidfixierung zur Stabilisierung distaler Klavikulafrakturen.

Shoulder

The Arthrex® clavicle plates are used for fixation of the midshaft and in distal clavicle fractures. Stability of distal fractures can be enhanced by integrating coracoid fixation into the plate using a knotless clavicle plate button and a Dog Bone™ Button.

Distal Clavicle Fracture Repair Using Coracoid Fixation

The Arthrex clavicle plates are ideally suited for fixation of mid-shaft and distal clavicle fractures. Stability of distal fractures can be enhanced by integrating coracoid fixation into the plate, using a knotless plate button and a dog bone button. Reduce the fracture and temporarily fix the pre contoured plate onto the clavicle. Place the drill guide into the appropriate plate slot and drill a bicortical hole. Measure for the screw length and insert the screw until it seats flush into the plate. Thread the distal drill guide into the plate and insert a guide sleeve. Leave the guide sleeve in place and drill a bicortical hole. Measure for screw length and insert the screw through the guide sleeve until it seats flush into the plate. Repeat for the other desired screws. Place the AC guide at the base of the coracoid. Place the drill sleeve in the plate slot and drill a three millimeters tunnel through the clavicle and coracoid. Remove the guide and retrieve a FiberStick through the drill. Shuttle the knotless TightRope loops through the bone tunnels and attach a dog bone button to the loops. Shuttle the loops until the dog bone button seats at the base of the coracoid. Cinch the Self-locking TightRope loops until the plate button seats into the plate. Cut the free suture limbs to complete the knotless repair.

Charles J. Jordan, MD (Miami, FL), demonstrates a distal clavicle fracture repair using a distal clavicle plate and distal clavicle Knotless TightRope® implant. The distal clavicle Knotless TightRope implant is passed through the clavicle and coracoid with a “push-through” technique for coracoclavicular fixation. The holes in all distal clavicle plates are designed to accommodate the distal clavicle Knotless TightRope implant.

Distal Clavicle Open Reduction Internal Fixation With a Distal Clavicle Plate and a Distal Clavicle Knotless TightRope® Implant

So today we're going to be doing an open reduction internal fixation of a clavicle fracture along with a coracoclavicular ligament disruption. This particular specimen has really great bony landmarks, but I generally try to cheat my incision a little bit inferior in order to gain better access to the coracoid. The coracoid process is just below. You can see the level of mobility here because of the simulated disruption of the coracoclavicular ligaments. And this is our fracture site. We've used a modified, what I call a modified compression clamp, where I've straightened the tines out of a reduction forceps or a towel clip, and made two pilot holes. And I've just been careful to keep it out of the way of where I'm going to place my fixation. I've chosen a superior distal clavicle plate. There's a cluster of screws at the distal end of the plate that accommodate 2.7mm screws. The proximal portion of the plate, the oblong holes, will accommodate a distal clavicle. Tightrope. So we'll start off with a bicortical screw. And I've measured from the drill. So I'm going to ask for an 18. We can also take this off and use a standard depth gauge. And again I'll take an 18. We'll use a non-locking screw first in order to bring the plate up against the bone. Okay. So now when we have provisionally fixed the distal side, depending on the amount of comminution, depending on the quality of the bone, 1st May want at this point to gain additional points of fixation before I use the medial oblong holes for compression. We elected to start off with three points of fixation in order to really anchor the distal portion of our clavicle plate down. Now, at this point I'll generally move to the proximal portion of the plate. One important thing to keep in mind is that I want to actively compress at the fracture site in order to achieve healing, and so I'm going to drill eccentrically. So what we'll do here is we'll get right up against the plate until I feel a little bit of tension, a little bit of push back on the plate. And then we're going to take the tack out and allow the plate to compress the fracture. And so in situations where you have really good bone quality or very good bony apposition, and you want to compress for a second time or compress further, you can bring a second screw up against the plate here. And once you get to the level of the oblong hole, you loosen this one. Now, the compression that you've already achieved is not going to recoil, because this screw is already holding it in that position. All it's going to do now is it's going to compress the fracture further distally. I filled the rest of the holes in the distal fragment with two seven locking screws. You'll also notice that the central screw that I had originally used, a cortical screw. I changed out to a locking screw. What we're going to do, basically, is place this pin through the hole in the plate down into the coracoid process, essentially judging the central location based on the position of my Homans. It's from time to time we will take a confirmatory X-ray. And basically I want to see that my guide Pin is aiming towards the center of the coracoid. And you can see very subtly that I just barely advanced through a couple of millimeters right in the center of the coracoid. The the angle of the image makes a big difference to you really want to get a good circular shot of the coracoid in order to know that you're down the center? The ideal position would be right there, just past the button, past the bone, but no further. So we're first going to remove the safety tab. I've loosened this. I'm going to remove the button and pull up. So what I will do is take the two limbs from each hole that are coming from each hole in the button, and just kind of give it a little sequential side to side pull and then take an x ray. The option of a knotless TightRope is really useful in this particular part of the body, being that the clavicle is such a subcutaneous structure, not having the prominence of a knot is very helpful.

Gregory S. DiFelice, MD, (New York, NY) demonstrates his technique for distal clavicle fracture repair utilizing a clavicle plate and knotless clavicle plate button. He applies trauma principles by using fluoroscopy to drill the clavicle and coracoid tunnels and to pass the knotless clavicle plate button, eliminating the need to access the underside of the coracoid.

Distal Clavicle Fracture Repair

Today we're going to talk about a new device, the Knotless clavicle plate TightRope. And you can see it here. We've had this developed more for the trauma surgeons and the guys who are dealing with twoby fractures that don't want to get involved with arthroscopy of the shoulder to pass their devices. And this makes it quick and simple and bases it off of a trauma approach, kind of like the old Bosworth screw, but with a modern day sports medicine take on it. Okay, so we can see here we've got a cadaver shoulder, and we've gone ahead and taken the liberty of placing a distal clavicle plate with just a couple provisional screws. And what I wanted to show you was the setup here. Typically, what I'll do is do this case in the beach chair position, and I'll bring the large fluoro machine in and I'll step inside the fluoro circle. So I'll stand here inside the arm and I'll fluoro from front to back. It only takes a few quick spot views. So if you're worried about dramatic amounts of exposure it's really not going to happen in happen in this case, because it's a fairly simple way of fixing these types of fractures. So what we'll do is line up the fluoro, get a good shot of the clavicle and the coracoid relationship, which is usually distorted a bit from the fracture. And then we'll line up where our drill pin is going to go when it comes through the drill hole. So we've lined up the plate so that our drill hole is directly over the coracoid, and we're going to put it in one of the oblong holes right there. This procedure bases everything off of the fact that at heart, we're all trauma surgeons, and we've all drilled bicortical into tenuous areas, and with care, we can avoid injuring the neurovascular structures. So what we're going to do is drill bicortical through the clavicle, and then we'll palpate the coracoid below us and then drill bicortical through that. Now we're coming through the coracoid one cortex and then the second cortex right there. As you can see nicely now our device here is rather simple. Distally we have an angled button with a knotless TightRope woven through it. Up top we have a handle and inserter. The button is held on by a threaded pin, and up top we have our plate button that will Nestle into the eyelet of the plate. So we're going to start to place our button. Now on Flora. We can see we've gone through the clavicle and entered the the coracoid. Now as we pass it down now we're passing through the coracoid there we've passed through the coracoid. And now we can release our button, unscrew the threads, take out the pin. Remove the red grommet that protects the sutures. We can take the button out of its little holder, undo the sutures, and now we can remove our handle. If we look inside the shoulder, we can see that the button has deployed nicely under the coracoid, and now it's really just a matter of cinching up our TightRope, which is pretty standard for all of us. And you can see how nicely that nestles down into the clavicle plate. And the final view shows the knotless clavicle plate. Tightrope that's been deployed just takes a few minutes to do. Some folks like to back it up with a half hitch or two, but you don't really have to. Given the studies that have been done on the TightRope, that's personal preference. Simply cut those sutures short and you're done with the deployment of that anchor. So here we have a nice clean trauma approach to twoby distal clavicle fractures where the ligaments have been torn. That allows you to get a nice flexible fixation between your plate and the coracoid distally. It's simple. It's easy. It's reproducible. And with the basic trauma skills that we all have can be done in a safe fashion.

Gautam Yagnik, MD, (Miami, FL) demonstrates his technique to treat distal clavicle fractures utilizing a Dog Bone™ Button with FiberTape® suture and augmented with an allograft wrap. Dr. Yagnik explains how this technique can be effective for distal clavicle fractures that are not amenable to plate fixation due to fracture location, severe comminution or ligamentous disruption.

Hi, my name is Gautham Yagnik. I'm going to be demonstrating fixation of a distal clavicle fracture using a dog bone for our primary fixation, as well as a allograft reconstruction for our CC ligament reconstruction. This technique is particularly useful when you have a very comminuted fracture or a very small lateral fragment, and you don't think that you would be able to get adequate fixation with a plate. We have a left shoulder. I use a standard bra strap or transverse incision here. I think this gives you a nice access to the distal clavicle as well as to the coracoid, which is important for this technique. Here's our fracture line. You can see our AC joint is here. So this lateral fragment is quite small. And this is a typical fracture pattern that you would see. And a lot of times this lateral fragment will be very comminuted as well. So getting adequate fixation with other forms of devices may be difficult things like a distal clavicle plate. So this gives you another alternative. I'll show you our technique here. For the first part of this procedure we use good fracture principles. Exposure fracture. Remove any interposed soft tissue so you can get a adequate reduction. And that's what you see here. So the next step in this technique is passing around the coracoid. As we're going to pass both FiberTape as well as a semitendinosus allograft around the coracoid. After you expose the fracture, the next step is to pass your tapes and graft around the coracoid. So I like to use this coracoid passer. It's a newer one that's in line. So it can help keep your incision small. You can go lateral to medial or medial to lateral using this device. In this case we went lateral to medial. We use a FiberStick as our shuttle. So for the next step we like to use this flexible obturator. It's a nice device here that can clear any soft tissue around the coracoid and prevent any soft tissue from from impinging or catching your graft or your tapes as they go around. So we're going ahead and passing our obturator. And once we get our obturator pass, we know that we have a nice clear path around the coracoid that will accommodate both our tapes and our graft. So in the next step here, we'll pass two fiber tapes, one blue and one tiger, as well as a second shuttle suture that will be used for our graft. So we'll pass the two tail ends so it creates a loop. So now we'll go ahead and use our our obturator to shuttle our sutures around the coracoid. So we got our two tapes that are passed around the coracoid our white and our blue. And then we have our shuttle suture here for our graft. So we'll go ahead and bring our graft onto the field, pass our graft around the coracoid. And then we're done with all our coracoid passage and we can focus on our fracture fixation. So this is our graft. It's a standard semitendinosus allograft prep here. I like to graft anywhere from 100 to 120mm, depending on the size of the patient. We use a FiberLoop on both sides to whipstitch the edges. We want at least 60 because I'd like to have some suture in the tunnel to to grab the screw. As we're going to place our screw down the center of the of the graft and compress it into the side. So here we go. We go ahead and pass our graft. And then we can kind of clamp these FiberTape together and clamp our graft together and place them off to the side while we prep the clavicle. So now we turn to our clavicle prep And the first thing I like to do is to drill our hole for our FiberTape sutures in our dog bone. This is going to be our primary form of fixation, so we want to get this as close to the fracture site as we can where there's good bone. So in this scenario, I think placing this about here will give us a nice spot for our pin. What we use here is a two for drill, and we create a two for bicortical hole through the end of the clavicle. For our second tunnel is going to be a six millimeter tunnel and that's going to accommodate our graft. This is going to be for our soft tissue fixation for this tunnel. I like to go at least 15mm medial to give us a nice bony bridge between the two tunnels. Sometimes you have to cheat this tunnel over a little more medial, depending on your fracture pattern and how comminuted your fracture is. But give yourself a nice, safe, soft, a nice, safe bony bridge here to minimize your risk of iatrogenic clavicular fracture. So in this case, we'll go approximately 18 or so millimeters. And this is where we'll create our our second hole. And again I center this right in the center of the clavicle. We leave this guide pin in here. So then we'll go ahead and use our six millimeter reamer over our guide pin to create our tunnel. And there you have your tunnel. So your clavicle prep at this point is is essentially complete. One thing we do like to do at this step is to use the chamfer from the UCL tray to open up the cortex here, as the cortex can be quite hard and you can have some sharp edges here. So this is the, the chamfer from the from the UCL set. It really countersinks and opens up, opens up this tunnel very nicely. It fits perfectly. Kind of rounds the cortical entrance for this bone tunnel and allows your graft to really sit down there and without the risk of cutting or amputating the graft. There is. So we'll go ahead and get our shuttle sutures. We can use a FiberStick here to go ahead and shuttle. Perfect. So we'll go ahead and and then we'll go ahead and repeat this step. Now we're ready to pass our tapes and our graft and start our final fixation. So another pearl here is I like to pass the tapes first. I think it's important to pass your fiber tapes first so that your graph sits anterior to your FiberTape, so there's no risk of compressing or over compressing your graph. And we're able to kind of takes a little bit of work to get it up through this two four drill hole. But you can get them. And then we go ahead and sequentially bring the slack out. Do the whites first and then we'll do our our blues. Before we go ahead and do our final tensioning there. We do want to pass our graph because once we tension down our dogbones, we won't be able to pass our graph. So we pass everything and then we do our final fixation. So as we go ahead and pass the graph, we go ahead and pass all our tails together. And once we get our tails through, we we pass both ends of the graphs and what usually again, we have a TigerWire on one side and a FiberWire on the other to help differentiate the two tails of the graph. So we kind of bring them up one at a time, with the thicker side usually going first. So now now we go ahead and pull one one end of the graph up first. And then we go ahead and pull our second end of the graph up as well. So it's sometimes a little bit of work to get these graphs up in there. And you do want it to be a little bit snug. So you get a nice fill of this tunnel. Now we've got everything passed and we're ready for our final fixation. So again, for for demonstration purposes, you wouldn't necessarily see this when you're doing the case live, but I think this is important to show you the, the construct from the undersurface. And what you have is you have your tapes running posterior. They're passed around the coracoid and coming up through your your 2.4mm drill hole. And then you have your graft, which is sitting anterior to the tapes around the coracoid and up through your six millimeter hole, reconstructing your soft tissue CC ligaments, which connect your coracoid to the undersurface of the clavicle. So now we're ready to tie our dog bone down. So we go ahead and separate our whites and our blues. And you can see, even without even putting our dog bone in, just the friction between the tapes inside, this 2.4mm hole is already compressing the fracture and reducing it. So now we're going to fix it. So this is our dog bone button. And we're going to pass our four limbs through. Once we pass all four limbs then we can start to to bring this dog bone down to the top of the clavicle here. And then it helps at this point to have your assistant kind of hold the dog bone exactly where you'd like it. I think placing it in this Orientation provides the maximum amount of compression, and you can see how it really hugs and contours very nicely to the clavicle. So we'll get our additional slack out both sides. And then what I'll do is go ahead and pick one of your tapes. In this case we're going to use the TigerTape. And we're going to go ahead and we're going to tie this down. So what by tying these sutures, what you're doing is you're reducing your medial fragment to your lateral fragment and reducing your fracture. It also provides a tremendous amount of compression across the fracture site. Then we go ahead and we tie our blues. Once we tie our dog bones down, you can see that we have a nice reduction of our of our fracture. Here's our AC joint. Here's our fracture line. We've brought the medial end down to the lateral end. We have compression across the fracture site, and now we go ahead and complete our biologic fixation with our graft, which adds a second point of stability to our construct and also recreates the soft tissue attachments between the coracoid and the clavicle. We make sure we get all the slack out of this graft, and then we can use the graft to help with our reduction. And what I like to do here is have my assistant first pull up to make sure they're getting any slack out of the graft, and then they will spread the graft here. So they're again compressing the medial end of the clavicle. To fix the graft we use a 5.5mm biocomposite tenodesis screw. And we go ahead and place this graft down right in the center of the graft and compress it into the wall. So this tenodesis screw is very helpful for that, because you have this metal tip that allows you to get down into the center of the tunnel. And at this point, you make sure your assistants are pulling the appropriate amount of tension here. And then you can go ahead and fix your graft. You can check it to make sure you're not proud. And then you go ahead and just pull this out. So this is your final construct here. You have your your dogbone with your fiber tapes that are providing your primary form of compression and fracture fixation. You have your biologic semitendinosus allograft providing your biologic second point of fixation and also recreating and reconstructing your coracoclavicular ligaments. And at this point, we go ahead and cut the graft flush to prevent any hardware irritation. So we do have a little pearl here for the notch stack. Sometimes these can be prominent. And in thin patients they can irritate. So one thing we've we've done recently which has really helped is we use we we use a free needle and we actually use these futures to help us with our deltoid repair. And it helps to bury the knot stacks. So let me show you that. And I like to use just a simple horizontal mattress configuration here. And this serves two purposes. One it's going to bury your knot stack. And the second thing is it's going to help you to repair your deltoid. So you can see this is already starting to to happen here. This little pearl is particularly helpful in helping to bury your knot stacks. And also to get a nice repair of your deltoid back down to your clavicle. And since we've been doing this, we have not had any issues with hardware irritation or not stack prominence. And that's your final construct.

Peter Millett, MD, MS, (Vail, CO) demonstrates arthroscopically assisted coracoid fixation to treat lateral clavicle fractures utilizing a clavicle plate and a knotless clavicle plate button. The plate button is preassembled with a knotless TightRope®‐like suture and is designed to be used with a Dog Bone™ Button and an Arthrex® distal clavicle plate. Dr. Millett shows how the combination of a plate and knotless coracoid fixation can give the surgeon a strong, knotless, low profile repair option to treat difficult lateral clavicle fractures.

Distal Clavicle Fracture Repair - Utilizing a Knotless Coracoid Fixation Device

My name is Peter Millett. I'm here at the Arthrex headquarters in Naples, Florida. Today we're going to demonstrate an arthroscopic CC fixation with integrated Knotless TightRope plate button for distal clavicle fracture. We have the Arthrex clavicle plate system. We have the plates here that are pre contoured and left and right, with different angles and different lengths available. We're going to demonstrate in this cadaveric demonstration using a distal clavicle plate which has multiple locking and non-locking screw options. In this cadaver one of the difficulties we have with distal clavicle fractures is sometimes it will also involve the CC ligaments. In order to perform CC fixation, you have to drill through the clavicle and through the coracoid. And this guide allows you to perform that. We have a three millimeter cannulated drill which will drill through this guide. And we'll remove the center cannulation. And then we can insert a TigerStick which will go through the center Cannulation that will allow us to shuttle a TightRope type device. This is a knotless device. There's an integrated plate button which will go on the proximal superior aspect. And there's a dog bone fixation button, which will go as a cortical fixation button on the coracoid surface on the bottom of the coracoid. This is a right shoulder. First step is to expose the distal clavicle. Usually we use a longitudinal incision from medial to lateral. Expose the fracture site. For this type of plate it's usually around the CC ligaments, which are about three and a half to four centimeters from the end of the clavicle. We'll reduce the fracture, obtain fixation with the plate medially and laterally as shown here. And then at this point, once this is reduced, we'll leave these center drill holes open here. And we can choose one of these for our CC fixation button. At this point we'll then go to a diagnostic arthroscopy. And in this case we have an arthritic shoulder. But we'll open the rotator interval. We'll go between the middle glenohumeral ligament and the superior glenohumeral ligament. Create an anterior portal as you see here. And then we can expose our coracoid process. This is 70 degree scope which really facilitates visualization using a trans articular approach. And you can see the base of the coracoid here as it approaches the anterior portion of the scapular body. And then we can see the medial aspect of the coracoid here and the lateral aspect here. And the base of the coracoid is where we want to place our drill hole for our CC fixation. So once that's been exposed, we'll take our drill guide. This is the adjustable drill guide. It's the same one we use for arthroscopic AC joint fixation that will fit through an eight millimeter cannula. And this is articulated so that it can rotate to fit the base of the coracoid. It also has a little arm on the distal aspect of the guide that can lock on the medial aspect of the coracoid. We can back our cannula up, ensure that we like our position, and then what we can do is we can just rotate the guide and figure out which hole we want to enter on the clavicle superiorly. So we'll lock it in place at this point, and then we'll make sure that we have good position on the base of the coracoid here. And at this point we can then drill the cannulated drill in place. So this will go through the plate through the bone of the clavicle which we just went through into the coracoid. And then it should exit right in that cutout in the drill guide. Good. Right. We can detach the Attach the drill, and then what we'll do is we'll screw the cannulation in, because sometimes we can get a little bone in there, and that would block us from placing our passing wires. So we just screw that in a little bit to advance the pin, make sure that there's no bone, remove the cannulation and we can take the guide out. At this point. Leave the drill in place. I'll come in with a KingFisher through my anterior inferior portal, and then we'll feed a TigerStick through the drill, retrieve that out our cannula, and then once we have that pass, now we can remove this drill. Sometimes you can remove it by hand. Sometimes we need to put the chuck on. So here you can see we've got a passing suture through the clavicle plate superiorly through the clavicle and through the coracoid. So we're going to shuttle this from superior to inferior. The button remains on top. There it goes. Good. Now what we can do is take the passing suture off. So the passing suture is off. Now, now we have a have a button. This is a dog bone button with slots on either side. We can lock that in anteriorly and posteriorly. And then at this point we will grab this with a KingFisher grasper and orient it lengthwise so it slides down the cannula easily. And then we'll pull the button superiorly. Just pass that through the cannula there and direct it in place. Good. So that's fixed on the bottom of the coracoid. And now at this point we'll then toggle it into position and it'll snap into the plate which I just felt it snap in. And at that point it's flush. And you have the additional fixation of the CC ligaments now of this device. And we can cut it. And that's flush. And you can place your additional screws here medially with the holes we didn't use for the button. And you can place additional screws laterally as needed. But you have the additional fixation of having CC fixation with the coracoid button inferiorly. There's a dog bone button there and then a superior button that's not listed. It's integrated into the plate.

Clavicle Plate and Screw System Surgical Technique

Klavikulaplatten und -schrauben

Foot and Ankle

Hand and Wrist

Das Minifragmentsystem (oder „Mini Frag“) wurde zur Unterstützung der Reposition und Fixierung bei traumatischen Verletzungen kleiner und langer Knochen entwickelt. Die Modularität des Siebs bietet Schrauben- und Plattenoptionen in den Größen 2, 2.4 und 2.7&nbsp;mm. Das Minifragmentsystem stellt mit seiner umfangreichen Auswahl an Platten für eine Vielzahl von Traumabedürfnissen eine wichtige Ergänzung des Traumaportfolios von Arthrex dar.
Eigenschaften und Vorteile
<ul>
 <li>Repositionsinstrumente und 6&nbsp;Plattenbiegeoptionen für die Bedürfnisse von Operateur:innen und Patient:innen</li>
 <li>Verstärkte Plattierungsoptionen für alle 3&nbsp;Plattengrößen verschaffen eine zusätzliche Stabilität, wenn ein stärkeres Konstrukt benötigt wird</li>
 <li>Eine große Auswahl an Platten und Schrauben (2&nbsp;mm Schrauben in Längen bis zu 40&nbsp;mm und 2.4&nbsp;mm und 2.7&nbsp;mm Schrauben bis zu 80&nbsp;mm)</li>
 <li>Das geteilte Siebdesign sorgt für intraoperative Effizienz, da gleichzeitig die geläufigen Instrumente und die größenspezifischen Caddies sofort verfügbar sind, was den Platzbedarf des Systems insgesamt reduziert.</li>
 <li>Jeder Caddy verfügt über eine kompakte Instrumentenschublade mit größenspezifischen Kurzinstrumenten</li>
</ul>
Indikationen
Das Minifragmentsystem ist indiziert für Frakturfixierungen, Rekonstruktionen, Replantationen, Stabilisierungen, Repositionen, Fusionen, Osteotomien, Fehlheilungen und Pseudarthrosen von kleinen Knochen und kleinen Knochenfragmenten, einschließlich normaler und osteoporotischer Knochen bei erwachsenen und jugendlichen (12&nbsp;-&nbsp;21&nbsp;Jahre) Patient:innen. Das System ist außerdem für die nichtlasttragende Stabilisierung und Reposition von Knochenfragmenten in langen Knochen indiziert.

Platten

Humerus-Plattensystem

Klavikulaplatten und -schrauben

Minifragmentsystem 2 mm / 2.4 mm / 2.7 mm