Hombro

Botón para reparación Pec

El Pec Button de Arthrex que es un botón de titanio de 2,6 mm x 10,9 mm se usa para fijar tejido blando a hueso como postes de fijación, un puente de distribución, o para distribuir la tensión de la sutura por zonas de reparación de ligamentos o tendones. Cada extremo del botón tiene una cara angulada para permitir un efecto alternante cuando el botón hace contacto con la cortical opuesta, lo que hace que Pec Button sea perfectamente adecuado para la reparación de roturas del tendón del pectoral mayor al hueso. Se forma un orificio piloto unicortical con una broca de 3,2 mm y después de sujetar dos suturas FiberWire N° 2, el botón se inserta de manera unicortical usando el insertador. El Pec Button también está disponible en un Sistema de reparación con provisión de implantes e incluye cuatro botones con suturas y agujas adheridas, el insertador y la broca en un embalaje estéril.

Shoulder

Arthroplasty Shoulder

Elbow

Imaging and Resection

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application/pdf

Human

A comprehensive overview of a product team’s portfolio.

Ein umfassender Überblick über das Portfolio eines Produktteams.

Kataloge

Visão geral e abrangente do portfólio de produtos de cada segmento.

Catálogos

Descripción general y completa sobre la cartera de productos de cada segmento. 

Catalogs

Shoulder and Elbow - Next Generation in Repair and Reconstruction 2024

Orthobiologics

Preston Wolin, MD, (Chicago, IL) demonstrates a subpectoral tenodesis repair augmented with an ArthroFLEX®* acellular dermal allograft. The use of ArthroFLEX provides supplemental support and biological covering to the tendon-suture interface.
*ArthroFLEX is a registered trademark of LifeNet Health.

video

A video recording of a surgical technique on a live patient in an operating room setting or a cadaveric demonstration.

Eine Videoaufnahme einer Operationsanleitung an einem lebenden Patienten oder Patientin in einem Operationssaal oder eine Demonstration an einem Humanpräparat.

Operationstechnikvideos

Gravação em vídeo de uma técnica cirúrgica em um paciente em uma sala de cirurgia ou uma demonstração cadavérica.

Vídeos de técnicas cirúrgicas

Grabación en vídeo de una técnica quirúrgica de un paciente en un quirófano o una demostración cadavérica.

Videos de técnicas quirúrgicas

Surgical Technique Videos

Subpec Tenodesis With ArthroFLEX® Acellular Dermal Matrix

Hello, I'm Preston Wallen from Chicago. And what we're going to be demonstrating today is the use of the ArthroFlex patch as part of an augmentation procedure for the biceps tenodesis. Now, I will normally choose a point where we know the musculotendinous portion is going to sit right underneath the pectoralis, so that for me is roughly about 15 to 18mm proximal to the musculotendinous junction. We're going to approximate this just a little bit for demonstration purposes. Now you can see that this biceps tendon is a little more diminutive than you'd normally like. So this is kind of the ideal situation for using this patch. And I'm going to cut a patch that's going to give me the width a little bit more than the width of the tendon. And as I said before it's going to give me about Out 15 to 18mm of length. So now you can see that I've marked the shiny. Side. The shiny side is going to turn and go down. And then what we're going to do is. We're going to amputate our tendon. Then the thing that I found is the best way to. Do this is if we can just oppose these two together with the Alice, we should be able to sew it in. Perfect. So you can see that the shiny side is down. And now we're going to just start taking and sewing. With our number two. Fiberwire. And I'm going to start right there. And that'll be one side for me. And now we're just going to sew the patch into the native biceps tendon in a similar way. This is the construct of the patch sitting right on top of the native biceps tendon. And you can see that it sits almost perfectly right on top of it. So now we're going to go ahead and we're going to do our Biceps tenodesis with the BicepsButton. So now we're just going to load the small pec button. And so we go through in one hole. And we're going to want each of these to come back out so that they're on the same side as the line. And we'll do the same thing over here. And we can put one, one hemostat across both of them. And the next thing we're going to do is just drop our button down the hall so it sits easily, and we're going to unscrew this inner metal portion. And now we're going to test our sutures to be sure that the button is flipped appropriately. And we can see that it has. And then the next stage, the last stage is we're going to take this free needle on our needle holder. And we're going to run it from the posterior aspect of the tendon right back through the area of our graft and native tendon construct. We're going to grab both. The tendon and the and the patch. And ideally, what we'd like to do is try to put it underneath one of those loops of the Krakow stitch. So it has an in. It has its own internal post, so to speak. And so now we're just going to gradually tighten down on our graph construct along with our tendon. And that's pretty much the end of the procedure. You can see that you've got your native tendon sitting posteriorly. You've got your graft sitting on the ventral surface. And you've got your knot coming from posteriorly and running through the anterior surface and tying it back onto itself. By adding the patch on top of the tendon, you have maximized your resistance to the suture, and you've added to the strength of the native tendon.

Darren Friedman, MD, (New York, NY) demonstrates his technique for distal clavicle fractures using a plate and coracoclavicular fixation. After fixing the plate medially with screws and prior to inserting the distal screws, he drills tunnels through the clavicle and coracoid under fluoroscopic guidance, eliminating the need to expose the coracoid. A cortical button loaded with FiberTape® and FiberWire® is inserted under fluoroscopic guidance, flipped and fixed to the plate. The distal screws are then inserted to complete the repair.

Distal Clavicle ORIF with Precontoured Plate and Coracoclavicular Augmentation using a Cortical Button

X rays show this distal third clavicle fracture. The plan tonight is to plate this with the lateral third clavicle plate. We're going to augment it with some coracoclavicular sutures. Flip a small metal button to capture under the base of the coracoid, and there's going to be sutures running from that button up through the plate to augment our fixation. The incision is pretty much centered over the lateral third of the clavicle. I think it's important that you take a look and get out to the AC joint, because this plate is going to be sitting right off of that AC joint. So the more lateral the better. So you make sure you want to see that that joint capsule. [00:00:48] Going in to watch. So I find it easiest when doing these either proximal humerus fractures or clavicle fractures to bring in the sea arm from the contralateral side. And then it doesn't get in the way with what we're doing. So so it's hard to see because it's kind of tucked in. But this is a piece of comminution right here, which we've keyed in to this to the medial segment. This is the major right off Andy. That lateral piece. Here's the lateral segment which you can see on the x ray. The big segment. And there's another piece of anterior inferior comminution kind of deep in there which we which we brought back. Good picture. All right. Great. We'll take the plate please. We have some K-wires to get this provisionally reduced. So here's a plate. Nice thing about this plate. There's five options to lock laterally. Good good good. So now let's take a snap, please. Good. So let's see which hole we're not going to use. Let's try a picture there please x ray. So my guess is we're going to probably use this hole here x ray. So that's going to be our hole that we're going to use. Okay. Right in the middle it's we're going to for our coracoclavicular stabilization. So we're going to take the 2.5 drill bit now. Good. Beautiful. Good. Let's just take a picture. Make sure our x ray please. See how we look here. Beautiful. So you can see there the plates down. The fracture is reduced. Our coracoclavicular CC interval is is much improved. And we've got some provisional fixation on the lateral segment. So at this point, what I'd like to do before I actually put the locking screws in the lateral segment where we have the K-wires there I like to supplement with this Coracoclavicular fixation will actually help bring that medial segment down a little bit lower and help actually help with our reduction. Biomechanically if I were to put the lateral locking screws in now and then we put in the Coracoclavicular stabilization device, okay, you're not going to change the fracture sites. You're going to be fixed medial and lateral. So it's important to to do this prior to Definitiv fixation on the lateral side. So why don't we get the why don't we get the device set up. The button which is on the end here okay is a small little cannulation some screw threads on the tip of the button. So it's actually attached to the device. So here's our here's our construct. We've got one FiberTape one FiberWire going through. We're going to drop this straight down across all four cortices. Unscrew the back end okay. This is going to flip underneath the coracoid and we'll have that the sutures exiting the clavicle. So bring my hand a little medial x ray. Good. So I like that. That's pretty close. Now you guys see the coracoid juts out like a knuckle. Okay. So you don't want to be straight up and down, because if you do that, you're going to probably end up going into the scapular body. So you definitely want to drop your hand about 30 degrees posteriorly. That will help angle you towards that base of the coracoid picture. Good. So we're centered right over the coracoid there. I'm happy with that. So now I'm going to start to drill. I'm going to feel all four cortices. That's. That should be two right there x ray. Good. So we are pretty good I'm going to angle my hand a tiny bit medial. And let's see here I'm going to feel that's my third quarter. See I want to get a picture x ray okay I'm happy with that. And now we're going to go all the way down and that's four. For. And. Okay, we're through a picture. Beautiful. So my assistant's going to take the drill. Drill it out on power. And I'm going to I'm going to look at his trajectory, and I'm going to try to match it when he comes out. So go ahead and you can pull that out. Good. X ray okay. So I'm right there. Check another x ray. All right. So we're almost there. Could I have a mallet please. So now because we're close I'm just going to gently tap this down picture. All right. We should be good there. And to make this flip guys this one we just unscrew the cannulation. Okay. Let's take a picture there. [00:05:53] Yes. We're going to do that. Okay. Good. Let's see a picture there. All right. Beautiful. So we're captured. That looks great. So now we will take the button for the for the plate. So that's sitting flush in the plate there. Beautiful. This is the button right here. Okay. Without the sutures in it, the back side is beveled, which is really nice. So it sits right in the plate hole. Flush. So what Andy just did is he just loaded the sutures, put them through the two holes in that button, and then put that button in the in the screw hole that we used that we just drilled through. So now we're going to tie the sutures down creating some coracoclavicular compression. It will actually help bring our fracture together. It will actually help with our reduction. Good. That was the number two. Fiberwire that we just tied down. And now I'm going to take all the slack. Out of the tape. And I'm actually going to try to tie that knot on top. Good. Beautiful. And then what we'll do now is we'll take some irrigation, start to put in some of our lateral screws. Good. So that looks beautiful. So the coracoclavicular distance is restored. Our buttons flipped appropriately. Our reduction is close to anatomic. None of the hardware is close to the AC joint. So this. This is nice for my distal thirds. Okay. I usually keep them in a sling for four weeks. Nothing. No pendulums, no range of motion of the shoulder. They'll let them do. Supine range of motion of the elbow. And then after four weeks, they can start doing active and passive motion.

Reuben Gobezie, MD, (Cleveland, OH) demonstrates his technique for unicortical subpec biceps tenodesis using the Proximal Tenodesis Kit and Tension Slide Technique. The Proximal Tenodesis Button is 8.5 mm long and is pre-threaded onto an inserter. Angled ends on the button help promote a toggle effect when the button contacts the opposite cortex. The sutures can be loaded into the button to perform the tension slide technique to easily and reliably draw the tendon onto the humerus.

Unicortical Proximal Subpec Tenodesis

Hi, my name is Reuben Gibbs, and I'm the chief of shoulder and elbow surgery at Case Medical Center in Cleveland, Ohio. I'm here to talk about the pectoral biceps tenodesis using our new kit. First, I want to discuss the difference between a sub performed with a BicepsButton over the traditional interference screw. There are several reasons why I prefer the BicepsButton for the Bio-Tenodesis over the traditional interference screw. First, you can use a small 3.2mm drill hole with the kit that we've designed, and that is all the perforation you're going to need to perform the procedure. I prefer that to the eight millimeter hole that you make in the anterior cortex, which had been reported as a stress riser. The second reason I like the BicepsButton over the interference screw is for most surgeons, it's far more reproducible and easy to achieve a tensioned biceps tenodesis Fixation with a BicepsButton over an interference screw. Finally, I think that when you compare the strength of the fixation with a button versus an interference screw, it matches up very nicely and is at least as strong as that fixation technology. This is the kit for the biceps tenodesis. And essentially you have a few components here that I think are helpful. One is you're going to come package like this. This is separately sterilized but it's in the same kit. This is the holder for the BicepsButton. The button itself, as you will see later on, is beveled nicely there. And you can see that this is now 8.5mm long versus the traditional or the distal BicepsButton, which is about 13mm long. So the other component of this is the drill guide. And you'll see here I'm going to take it out of this kit here for you. And you're going to see here that this drill guide guide is slotted. And you can see the slot going through this here. And I'll show you how. That's very helpful, particularly in our more robust patients with large arms. It can be sometimes a little bit tricky to find that drill hole once you've made it. Since it's only 3.2mm in a really big arm, it can be difficult. So the guide we think will really help you. Finally, there's this. At least in the paper portion of this, there's the drill. It's a graduated drill bit. It's spade tipped as you can see here. And it's I think ample of ample length for most arms you're going to run into. And then you'll have a two more features in terms of sutures. One is a free needle. That's a straight needle, which is actually a FiberLoop. As you can see here, it's a looped suture, and it gives a very nice and even baseball stitch for fixing the biceps for the button. And then lastly there's the the free needle, which you're going to use in this kit, which is here. It's a nice big loop. So those of us who are challenged visually you can still get that number two FiberWire through this loop and lock the stitch in the biceps before you tie down the suture. Here I've outlined for you here's the humeral shaft. And then here's my faux pectoralis major tendon coming in and inserting. And as you all know, the actual site or the or the place of action occurs right underneath this. Some guys like to go and put it approximately, as is described about a centimeter above that pec inferior border of the pectoralis major. I personally put it right around the same place, with the goal being that we're going to you make an incision here. You put a Hohmann retractor. Like this over the edge of the the humerus, and then lever it out to give you a nice look at the at the bicipital groove. I think it is important when you do this to take the arm and ab duction here a little bit, and I think that takes tension off of the deltoid for you in a way that's nice. The other area where it varies from person to person is where they make the incision. You know, on a cadaver, it's a little bit hard because you have a four quarter amputation. You don't really get as much a sense of how this dimpling occurs in reality. I tried to make that the case here, but there's a dimpling and I try to aim the incision to the armpit, essentially just not in the deepest part of the axilla, axilla, but sort of right at the beginning of the armpit where that crease is. The goal being that when the arm, when the patient is awake and puts their arm to the side in, in real life, it would be somewhere like in here, you know what I mean? Where you really wouldn't see it on the arm. Alternatively, you know, to get the job done, quote unquote. You can make it literally anywhere on this line and successfully achieve the operation. It's just cosmesis wise, in my opinion, it opinion, it works best when you're closer to the axilla. There's the humerus here, but really, I want to go in here so that in surgery, I mean in post-op, they really can't see it. Okay, so I make an incision. I'm gonna make it a little bit bigger for the sake of this video than I normally wouldn't in real life. Just to show, to get the light in the incision. Then I put a senn here, retractor here, and I put a senn on this side. And it usually opens up the the armpit. And you'll find, even, as you know, during the surgery itself, that the skin stretches just to set it down until I get to the sheath of what usually is a conjoint tendon. I'm working towards the head and that's going to go towards the humerus. Now, again, keep in mind in a cadaver the muscles are on tension. I take this point at home in here, and I place it just like this over the side of the humerus, and this comes out. Then it goes like that and that. Just grab it at the end there. That's very good. And then this. This point at home in here. Mini baby home is over the lateral aspect of the humerus, pulling the deltoid back. This is the floor of the bicipital groove. Normally this tendon, because it's on a four quarter amputation, is anatomized above and below. It sits right there. Okay. It's sitting right up against that groove. And you'll see it like that when you when you retract with this here. The conjoint tendon which is this mass here. Like this guys. And there you go. Here's the musculotendinous junction there. And there's the rest of the tendon. It looks about that long. What I do then is I put a little snap on the end of the tendon here like that. Okay. And you see here here's a FiberLoop straight needle and the loop on the other side. And to prepare this, it's kind of nice because you get a nice even baseball stitch, if you will, around this tendon. Al and I are going to do this now. So what I do first is I take this loop, I open it up like this. I have Alan hold it here. And people ask oftentimes where do you tension it? Where do you tension this. And what I do is I've done it many different ways. I've done many tenodesis of the biceps. And you see here that the Musculotendinous junction here. Okay. I usually go just distal to the junction, literally a centimeter and a half or two centimeters. And I put the first, I put the first pin in there. But if you do a nice pattern, there's the baseball stitch. You get just distal to the musculotendinous junction. Cut the suture now okay. And then the next step is we're going to use this threaded inserter that you saw earlier. Here's the thread. This this piece threads into the button. The button itself is kind of interesting. You've seen it. We showed you on the back table there. This this button is beveled as you see here on one end. And the idea there is the same as the pectoralis major button. You want to flip it intracortical, and you want to get a geometry that is favorable for that kind of maneuver. The other thing I'll say about it is it's And a half millimeters long versus 13mm long on the typical distal BicepsButton. And that's because of the narrowed diameter of the proximal humerus at the isthmus or, you know, just proximal to the isthmus. Lastly, you see here this geometry with the beveled button tip. It really works best when you thread the sutures through the pointed end. So you see that this is I'm calling the pointed end that end there. Okay. So we're going to take the number two FiberWire and pass it through the center of that that loop there, which makes it usually easier. Okay. And then what we're going to do is take this free needle and pass it through the first of the of the holes like this. Okay. Then we're going to turn around and do the same thing passing it back like that. Okay. That's one loop. The second loop we're going to repeat as you're very familiar with already. We're passing it again through the night and through the loop in the free needle. The number two. Fiberwire. And this time we're going to go, and we're going to do it in the opposite strand where we come in like this, pass it in through this way, flip it around like this and pass it through the other way. That's how you that's how you that's how you pass that. And now you're ready. You got this thing locked and loaded. Thank you very much. And you're ready to go. I'm going to put this down. Sometimes you can snap this. You can if you want to. You can you can put a snap on this. So now we're going to go to the drilling section of this here. And I'm going to take this I'm going to take this base of the bicipital groove that you see there. And we're going to drill it. And once it gets drilled you see it fall into that groove there I back this out. You see the hole there. And without moving. I basically take this and essentially insert it right in there. There it goes. Okay. It goes in the hole there like that. So now you have this situation where you've got your your button in the canal. It's not flipped. You take your hand off of this. You put it here, you unlock the screw here and then you then you fill that flip happen. Once that happens, you take the sutures. You pull them one, toggle one, then the other, and then you'll have it flip against the back wall of the canal or the front wall and your wall, and then you're free to just take this off here. It pulls back like this and you pull it off. Okay. And usually it comes out like that. And then now you can just sort of toggle it up in there. And you see there the biceps is is down against the anterior wall of the humerus and or the bicipital groove. And you can see can see here that's what it kind of looks like. All right. The next thing you have to do, though is for the bicortical technique is you have to lock the suture through the tenon itself so that when you come down on the knot, you're going to have a construct where the knot actually sits on the tendon. The tendon is sitting on the anterior cortex of the humerus, and that is the button that's sitting on the back cortex of the humerus. So you have nice you do not want it where you have a knot lying essentially on the button bypassing the biceps. And we do have one other thing in this kit, which is essentially a suture anchor, I mean, a suture, a needle with a wire on it. And that should make it much easier. Again, here you you pass the suture one end through the suture. It doesn't matter which end. And then you take the biceps and you and I, what I do is I just do a locking stitch right through the end of that biceps like that. And then once that's done, I take a knot pusher. And you see here it's nice and trim there. I take a knot pusher like this. Pass my post stitch, which is essentially this stitch through the tendon through the knot pusher, and then obviously tie it down any which way you would like. So the last thing we'll go over is essentially I get a lot of questions about the post-op rehab protocol for a biceps tenodesis. I've done it in many different ways. And like many surgeries in orthopedics, especially shoulder, we have different protocols varying from person to person. In my practice, I'll do a. I feel very good about the fixation that I get with the BicepsButton, and I usually can. Most people can just be let fly, if you will. No heavy lifting for about 6 or 8 weeks. But but pretty much you can use your arm freely if you're more conservative and you want to protect against that 10% of people who aren't going to who are going to do crazy things if you let the if you will let the rope out. What I what I'll tell them is two weeks in a sling. They can eat, drink, shower and shave. And activities of daily living are fine. Passive range of motion in my practice starts within 2 or 3 days after the surgery, and by two weeks they can come out of the sling completely and start to use their arm for stretching and range of motion exercises. No heavy lifting for three months, but other than that, some manual workers, I tell them three months of no heavy lifting. But other other than that they can do moderate lifting at six weeks.

Hi, my name is Ruben Gomez and I'm the chief of shoulder and elbow surgery at Case Medical Center in Cleveland, Ohio. I'm here to talk about the biceps tenodesis using our new kit. First, I want to discuss the difference between a sub performed with a BicepsButton over the traditional interference screw. There are several reasons why I prefer the BicepsButton for the Bio-Tenodesis over the traditional interference screw. First, you can use a small 3.2mm drill hole with the kit that we've designed, and that is all the perforation you're going to need to perform the procedure. I prefer that to the eight millimeter hole that you make in the anterior cortex, which have been reported as a stress riser. The second reason I like the BicepsButton over the interference screw is for most surgeons, it's far more reproducible and easy to achieve a tensioned biceps tenodesis Fixation with a BicepsButton over an interference screw. Finally, I think that when you compare the strength of the tenodesis fixation with a button versus an interference screw, it matches up very nicely and is at least as strong as that fixation technology. This is the kit for the biceps tenodesis. And essentially you have a few components here that I think are helpful. One is you're going to come package like this. This is separately sterilized but it's in the same kit. This is the holder for the BicepsButton. The button itself, as you will see later on, is beveled nicely there. And you can see that this is now 8.5mm long versus the traditional or the distal BicepsButton, which is about 13mm long. So the other component of this is the drill guide. And you'll see here I'm going to take it out of this kit here for you. And you're going to see here that this drill guide guide is slotted. And you can see the slot going through this here. And I'll show you how. That's very helpful, particularly in our more robust patients with large arms. It can be sometimes a little bit tricky to find that drill hole once you've made it. Since it's only 3.2mm in a really big arm, it can be difficult. So the guide we think will really help you. Finally, there's this. At least in the paper portion of this, there's the drill. It's a graduated drill bit. It's spade tipped as you can see here. And it's I think ample of ample length for most arms you're going to run into. And then you'll have a two more features in terms of sutures. One is a free needle. That's a straight needle, which is actually a FiberLoop. As you can see here, it's a looped suture, and it gives a very nice and even baseball stitch for fixing the biceps for the button. And then lastly there's the the free needle, which you're going to use in this kit, which is here. It's a nice big loop. So those of us who are challenged visually you can still get that number two FiberWire through this loop and lock the stitch in the biceps before you tie down the suture. Here I've outlined for you here's the humeral shaft. And then here's my faux pectoralis major tendon coming in and inserting. And as you all know, the actual site or the or the place of action occurs right underneath this. Some guys like to go and put approximately, as Gus has described, about a centimeter above that pec inferior border of the pectoralis major. I personally put it right around the same place, with the goal being that we're going to you make an incision here. You put a Hohmann retractor. Like this over the edge of the the humerus, and then lever it out to give you a nice look at the at the bicipital groove. I think it is important when you do this to take the arm and ab duction here a little bit, and I think that takes tension off of the deltoid for you. And in a way that's nice. The other area where it varies from person to person is where they make the incision. You know, on a cadaver, it's a little bit hard because you have a four quarter amputation. You don't really get as much a sense of how this dimpling occurs in reality. I tried to make that the case here, but there's a dimpling and I try to aim the incision to the armpit, essentially just not in the deepest part of the axilla, axilla, but sort of right at the beginning of the armpit where that crease is. The goal being that when the when the patient is awake and puts their arm to the side in, in real life, it would be somewhere like in here, you know what I mean? Where you really wouldn't see it on the arm. Alternatively, you know, to get the job done, quote unquote. You can make it literally anywhere on this line and successfully achieve the operation. It's just cosmesis wise, in my opinion, it works best when you're closer to the axilla. There's the humerus here, but really, I want to go in here so that in surgery, I mean in post-op, they really can't see it. Okay, so I make an incision. I'm gonna make it a little bit bigger for the sake of this video than I normally would in real life, just to show, to get the light in the incision. Then I put a senn here, retractor here, and I put a senn on this side. And it usually opens up the the armpit. And you'll find, even as you know, during the surgery itself, that the skin stretches just to set down until I get to the sheath of what usually is a conjoint tendon. I'm working towards the head that's going to go towards the humerus. Now again, keep in mind in a cadaver the muscles are on tension. I take this point at home in here, and I place it just like this over the side of the humerus, and this comes out. Then it goes like that and just grab it at the end there. That's very good. And then this, this point at home in here. Mini baby home is over the lateral aspect of the humerus pulling the deltoid back. This is the floor of the bicipital groove. Normally this tendon, because it's on a four quarter amputation, is atomized above and below. It sits right there. Okay. It's sitting right up against that groove. And you'll see it like that when you when you retract with this here, the conjoint tendon which is this mass here like this guys. And there you go. Here's the musculotendinous junction there. And there's the rest of the tendon. It looks about that long. What I do then is I put a little snap on the end of the tendon here like that. Okay. And you see here here's a FiberLoop straight needle and the loop on the other side. And to prepare this, it's kind of nice because you get a nice even baseball stitch, if you will, around this tendon. Al and I are going to do this now. So what I do first is I take this loop, I open it up like this. I have Alan hold it here. And here. And people ask oftentimes where do you tension it? Where do you tension this. And what I do is I've done it many different ways. I've done many tenodesis of the biceps. And you see here the Musculotendinous junction here. Okay. I usually go just distal to the junction, literally a centimeter and a half or two centimeters. And I put the first, I put the first pin in there. But if you do a nice pattern, there's the baseball stitch. You get just distal to the musculotendinous junction. Cut the suture now okay. And then the next step is we're going to use this threaded inserter that you saw earlier. Here's the thread. This this piece threads into the button. The button itself is kind of interesting. You've seen it. We showed you on the back table there. This this button is beveled as you see here on one end. And the idea there is the same as the pectoralis major button. You want to flip it intracortical, and you want to get a geometry that is favorable for that kind of maneuver. The other thing I'll say about it is it's And a half millimeters long versus 13mm long on the typical distal BicepsButton. And that's because of the narrowed diameter of the proximal humerus at the isthmus or, you know, just proximal to the isthmus. Lastly, you see here this geometry with the beveled button tip. It really works best when you thread the sutures through the pointed ends. So you see that this is I'm calling the pointed end. That end there. Okay. So we're going to take the number two FiberWire and pass it through the center of that that loop there, which makes it usually easier. Okay. And then what we're going to do is take this free needle and pass it through the first of the of the holes like this. Okay. Then we're going to turn around and do the same thing passing it back like that. Okay. That's one loop. The second loop we're going to repeat as you're very familiar with already passing it again through the night and through the loop in the free needle. The number two. Fiberwire. And this time we're going to go, and we're going to do it in the opposite strand where we come in like this, pass it in through this way, flip it around like this and pass it through the other way. That's how you that's how you that's how you pass that. And now you're ready. You got this thing locked and loaded. Thank you very much. And you're ready to go. I'm going to put this down. Sometimes you can snap this. You can if you want to. You can you can put a snap on this. So now we're going to go to the drilling section of this here. And I'm going to take this I'm going to take this base of the bicipital groove that you see there. And we're going to drill it. And once it gets drilled you see it fall into that groove there. I backed us out. You see the hole there. And without moving. I basically take this and essentially insert it right in there. There it goes. Okay. It goes in the hole there like that. So now you have this situation where you've got your your button in the Intra-articular canal. It's not flipped. You take your hand off of this. You put it here, you unlock the screw here and then you then you fill that flip happen. Once that happens, you take the sutures. You pull them one, toggle one, then the other, and then you'll have it flip against the back wall of the canal or the front wall and your wall, and then you're free to just take this off here. It pulls back like this and you pull it off. Okay. And usually it comes out like that. And then now you can just sort of toggle it up in there. And you see there the biceps is, is down against the anterior wall of the humerus and or the bicipital groove. And you can see can see here that's what it kind of looks like, right? The next thing you have to do, though is for the bicortical technique, is you have to lock the suture through the tenon itself so that when you come down on the knot, you're going to have a construct where the knot actually sits on the tendon. The tendon is sitting on the anterior cortex of the humerus, and that is the button that's sitting on the back cortex of the humerus. So you have nice you do not want it where you have a knot lying essentially on the button bypassing the biceps. And we do have one other thing in this kit, which is essentially a suture anchor, I mean, a suture, a needle with a wire on it. And that should make it much easier. Again, here you you pass the suture one end through the suture. It doesn't matter which end. And then you take the biceps and you. And now what I do is I just do a locking stitch right through the end of that biceps like that. And then once that's done, I take a knot pusher. And you see here it's nice and trim there. I take a knot pusher like this. Pass my post stitch, which is essentially this stitch through the tendon through the knot pusher, and then obviously tie it down any which way you like. So the last thing we'll go over is essentially I get a lot of questions about the post-op rehab protocol for a biceps tenodesis. I've done it in many different ways. And like many surgeries in orthopedics, especially shoulder, we have different protocols varying from person to person. In my practice, I'll do a. I feel very good about the fixation that I get with the biceps button, and I usually can. Most people can just be let fly if you will. No heavy lifting for about 6 or 8 weeks. But but pretty much you can use your arm freely if you're more conservative and you want to protect against that 10% of people who aren't going to who are going to do crazy things if you let the if you will let the rope out. What I what I'll tell them is two weeks in a sling. They can eat, drink, shower and shave. And activities of daily living are fine. Passive range of motion in my practice starts within 2 or 3 days after the surgery, and by two weeks they can come out of the sling completely and start to use their arm for stretching and range of motion exercises. No heavy lifting for three months, but other than that, some manual workers, I tell them three months of no heavy lifting. But other than that, they can do moderate lifting at six weeks.

Matthew Provencher, MD, (Boston, MA) performs pectoralis major repair using the new Pec Repair Implant Delivery System. He performs a detailed dissection to describe all relevant anatomy and demonstrates the benefits of combining FiberTape® with titanium Pec Buttons to securely and anatomically reattach the tendon’s small footprint. The new 3.2 x 11 mm Pec Button is mounted on a threaded inserter and has large eyelets that can accept FiberTape with needles. The ends of the button are chamfered to facilitate easy unicortical flipping.

Pectoralis Major Repair using the Pec Button Cadaveric Demonstration

Hi, my name is Matt Provencher. I'm from the Massachusetts General Hospital in Boston, Massachusetts, and I'm here to demonstrate a pectoralis major tendon repair using the pectoralis major tendon repair kit. As you can see, I'm highlighting here basically the sternal head and the clavicular head in a right shoulder specimen. This area here is the area of the incision. And it's approximately a 3 or 4 centimeter incision, depending on the extent of tear. The vast majority of your pec tears are sternal head, but may also involve the clavicular head in 10 to 20% of the cases. Thus, the emphasis of the incision is in the inferior part of the sternal head of the pectoralis major. I use about a four centimeter incision. It's a deltopectoral approach, and for the cadaveric demonstration, I'm going to make this incision a little bit longer so that we can easily see this procedure. And also the anatomy of the pectoralis major and also the footprint which we are trying to restore. I do this in the beach chair position with the head elevated about 40 to 45 degrees, and the arm either on a mayo stand or in a TRIMANO holder just below the pec tendon. And what I'm trying to identify and find here is the long head of the biceps muscle. So here is the pec tendon insertion. There you can see the size of the pec tendon. It's pretty small. And you can see that it's not much bigger than the end of my thumb or the distal phalanx before you get out to the muscle. And this is very typical of those that do a lot of lifting and bench press, which are the people that get these injuries in the first place. So they'll have a lot of muscle in the pectoralis major unit and generally a very small tendon. What I'm demonstrating here now is the long head of the biceps tendon. The long head of the biceps lives just medial in a shallow groove to the pectoralis major tendon insertion. Thus it comes just deep and medial to the pectoralis major. I gently retract that out of the way. And here I'm demonstrating the shallow biceps groove, and then also the area of the pectoralis major tendon insertion. Here is the tendon unit of the pectoralis major tendon, tenant. As I indicated earlier, this can be a pretty small tendon structure. And here's the pec attachment relative to the biceps groove. So I'm grabbing right now is the pec tendon attachment. And I've taken off about the bottom three centimeters or most of the sternal head. And you can see that it's a pretty robust area of bone. One of the problems with a traditional repair technique with humeral tunnels is that in order to do this repair, the tunnels really have to start quite medially as I'm demonstrating here, which is in the biceps groove and my thumb is going up and down that biceps groove. But the trans humeral or bone tunnels would actually realize this repair quite a bit and cause potential incarceration of the long head of the biceps, which is shown right under here. At this point, I'm now showing the undersurface of the pec major, and this fascia area is very nice. And you can take advantage of this in more chronic cases or cases that don't have a large tendon unit in order to help hold the suture for your repair. So my instrument is holding the pec tendon, and I'm tracing out some of the fascia Posteriorly, which holds the muscle in place. The design features of the pectoralis major button were to have it be an ease of insertion. Thus it has a screw in inserter, and one end of the button has threads in order to accommodate the screw in inserter, so you can easily insert it. Unscrew the peck button and then have it easily flip. The second thing that was important was also to have chamfers on each of the sides, which also allow the peck button to easily flip in a blinded fashion. The other thing that was important is that the peck button has a very smooth and rounded aspect on both of the holes, and also is wide enough to accommodate FiberTape a high strength FiberWire number five suture, or even both. At this point you can see that the pectoralis major tendon is quite small. The problem is that the muscle can come very far laterally and there's very little tendon to be repaired, and maybe this is only up to one centimeter. Thus, this is why I like the FiberTape suture because it's a non cylindrical tape type polyester suture which does not easily cut out and holds this tissue tendon unit very well. I start inferiorly here with a weave type stitch, but there's many different configurations you can use in order to hold this tendon unit prior to repairing it and putting it through the pec button. What I'm also demonstrating here is how the FiberTape comes posteriorly and posteriorly of the PEC is a very nice fascial area, so if you're having difficulty getting good hold, you can always go posteriorly on the back side of the pec. These are the high strength number five FiberWire cylindrical sutures. These are smooth needles such that they're non-cutting and will not damage the muscle tendon unit, and these can also be used and are especially helpful in cases that are chronic in nature, where you need to have a lot of pull on the tendon to get this reduced. And I like these high strength number five sutures to do the reduction. And then I back it up and reinforce it with the FiberTape, because I know the FiberTape holds very well in the tendon and muscle tendon area. So again, I use one end of this to go up the tendon, interlock it, and then come back down to the same area. So here's the bottom portion of the repair in these four sutures. Or two of the strands will be placed through the pec button. And then using a tension slide technique will be repaired. I'm now doing the superior portion of the repair. I've started with the FiberTape into the superior portion of the sternal head, and again in a weave technique. At this point, it's also important to prepare the bony bed, and you can use this with a combination of a rasp or very light decortication with a burr. What's important here, and I'm demonstrating with this diagram, is that you want to be center center and not be off. In order to allow this button to flip, it has to be living in the cancellous portion or the center core of the humerus. So you want to make sure that you're drilling center center and not through all cortex. And so that's what I'm showing here, is how the 3.7 drill is going in and out. And you definitely know that you're through the cortex and into the cancellous and central cylindrical portion of this, as I'm demonstrating here again, by just coming in and out and know that you have good room to flip. So for this repair we'll use two pec buttons. What I'm showing here is that it's important to make sure you put this suture in first in the hole that's closest to the inserter, so don't put it in that one, but put it in the one that's closest to the inserter first. I started with number five. You can either use 1 or 2 sutures, but I would not use any more than that because it would be too hard to allow this to slide. So that's the number five suture. And the strand comes out at the long side of the button or furthest away from the inserter. And I'm also showing here how I insert the tail of the FiberTape. And so I put the tail of the FiberTape in again starting closest to the inserter. And then I put it out at the long side of the button. And this is where the free limb comes out. I then pull enough of it in such that I have the tape in the button, as well as the number five in the button. So the chamfer goes into the tunnel. So once you have it into the tunnel, you feel that it hits the other side of the cortex. It's very important to unscrew this, but leave the inserter in. This will also help make sure that the button does not pull out and it flips. So once you've unscrewed it, you can push the inserter in. This helps the button flip and you also pull the suture free ends, while the inserter is also in to make sure that the button flips. I'm now showing how you can also load the peck button with needles, so if you leave the needles on, you can easily put the needles through the peck button again, starting first with the hole closest to the inserter, and the strand comes out at the long side of the button or furthest away from the inserter. After I put the second one in, I unscrew it and push it in and then cinch it down. So once I cinch it down, you can see how the tenon comes perfectly down to the anatomic position I'm using. First the number five distally to tighten this down, because the distal one can sometimes be the most tight to get and get it back anatomically. So thus I use the number five for my strength pole and then the FiberTape I cinch down and that's the tissue holding power stitch. You hold that tautly while you bring the other limb and tie it down. At this point I finish the repair construct with about 4 or 5 alternating half hitches. Cut the sutures and now you can see the pec tendon is repaired back anatomically to its perfect position. There is absolutely no impingement of the long head of the biceps, and the long head of the biceps is living natively back in its groove without any incarceration or impingement. So the rehabilitation of a pectoralis major tendon repair, I feel, is very important. I use a sling for about 5 to 6 weeks total. However, I start scapula exercises right away that includes low trapezius and low scapula strengthening. I also start passive range of motion right away under assistance, and that's passive range of motion with flexion to 90 degrees and abduction to about 40 to 60 degrees, depending on the strength of your repair. I stopped the sling at about 5 to 6 weeks, and increase full range of motion at that point, and start more of a strengthening program. It's key to avoid full bench press and other pressing activities until about 5 to 6 months. Post-operatively.

BicepsButton, 2.6 x 12 mm, titanium

BicepsButton, 2.6 x 12.0 mm, Titan, steril, IM

Spear w/Circumferential Teeth and Trocar Tip Obturator for 3.5 mm PushLock and 3.5 SwiveLock anchors, Reusable

Speer mit Zahnkranz für 3.7 mm SutureTak und 3.5 mm PushLock

Spear, for 3.7 mm SutureTak and 3.5 mm PushLock, Trocar Tip Obturatorwith Circumferential Teeth

Guía de broca para SutureTak Ø 3.7mm y PushLock Ø 3.5mm,obturador con

Orientador, para SutureTak 3.7 mm e PushLock 3.5 mm, com ponta em trocar com dentes em circunferência

BicepsButton Drill Pin, 3.2 mm, Sterile

BicepsButton Zieldraht, 3.2 mm, VE1, steril,

Aguja perforadora BicepsButton, Ø 3.2 mm

#2 FiberWire, 38", 2 Strands (1 blue, 1 white/black)

FiberWire #2, Geflochtener Polyblend Faden, 1x Blau & 1x Schwarz/Weiß,ohne Nadeln, steril

FiberWire #2 Braided Polyblend Suture, 1 Blue & 1 Black/White

FiberWire de calibre #2, hilo de sutura de Polyblendtrenzado, 1 azul y

2 FILAMENTOS – 1 AZUL E 1 BRANCO/PRETO TIGERWIRE

Sutura de polimistura entrançada FiberWi

FiberTape Suture, 2 mm, 17 in (blue), each end tapered to #2 FiberWire suture w/ tapered needle 26.5 mm, ½ circle, qty. 6

FiberTape mit Nadeln 17 Inch =43cm Tapelänge

FiberTape, 2 mm 34'' (86,36cm), 17'' Working Length Braided Polyblend Suture Blue with 2 Tapered Needles

FiberTape 2 mm, sutura Polyblend trenz. 86.36 cm, long. deuso de 43.18

Sutura de polimistura entrançada FiberTape, 2 mm, 86.36 cm, 43.18 cm decomprimento útil, azul, com 2 agulhas cónicas

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