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

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

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

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

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

Capsular Closure Technique Using a SutureCast™ Suture Passer

Capsular Closure Technique Using a SutureCast™ Suture Passer

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

Femoral Neck Cam Resection Using the Hip DiamondCut™ Burr

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

Femoral Neck Cam Resection Using the Hip DiamondCut™ Burr

The revolutionary TightRope SB™ implant eliminates metal hardware from ACL reconstruction procedures and features a suture-based button for cortical fixation. This animation demonstrates a QuadLink™ ACL reconstruction using the FiberTag® TightRope® SB implant with the InternalBrace™ technique.
The InternalBrace surgical technique is intended only to augment the primary repair/reconstruction by expanding the area of tissue approximation during the healing period and is not intended as a replacement for the native ligament. The InternalBrace technique is for use during soft tissue-to-bone fixation procedures and is not cleared for bone-to-bone fixation.

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

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

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

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

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

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

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

Rachel M. Frank, MD (Denver, CO), demonstrates an all-inside quadriceps ACL reconstruction using the FiberTag® TightRope® SB implant with the InternalBrace™ technique.&nbsp;
 
The InternalBrace surgical technique is intended only to augment the primary repair/reconstruction by expanding the area of tissue approximation during the healing period and is not intended as a replacement for the native ligament. The InternalBrace technique is for use during soft tissue-to-bone fixation procedures and is not cleared for bone-to-bone fixation.&nbsp;

Rachel M. Frank, MD (Denver, CO), demonstrates an all-inside quadriceps ACL reconstruction using the FiberTag® TightRope® SB implant with the InternalBrace™ technique.&nbsp;
The InternalBrace surgical technique is intended only to augment the primary repair/reconstruction by expanding the area of tissue approximation during the healing period and is not intended as a replacement for the native ligament. The InternalBrace technique is for use during soft tissue-to-bone fixation procedures and is not cleared for bone-to-bone fixation.&nbsp;

All-Inside Quad ACL Reconstruction Using the FiberTag® TightRope® SB Implant With the InternalBrace™ Technique 

I am Rachel Frank, a sports medicine surgeon from the University of Colorado in Denver. This is the all suture ACL reconstruction technique. No metal, no peek. So we will now demonstrate our soft button quad link ACL reconstruction. Here I'm going to demonstrate the harvest through a vertical incision. But you could certainly do a transverse incision if you're more comfortable with that. And we'll make our incision. And then during the incision and exposure one of the most important parts is to get rid of some of this subcutaneous fat. That's how you can keep your incision small while still getting good visualization. We've excised some of the fat, and we're kind of looking down on some of the peritenon on top of the quad. I'll take the Cobb elevator and I do an initial sweep and a second. We're going to switch to the Army navies. An initial sweep of the tissue. And then I'll switch to the Army navies once I take a sponge and get that in there and get really some of that soft tissue off. So then we have a nice view of the quad here straight down. And then what we'll do is we're going to take the scope and a marking pen so we can see the quad coming up. And basically I'll go right there and then I will relax my army Navy I'm going to take it out. I lever my scope up and then we can feel and see the light and we'll make just a little dot. And now I know where to aim to. I'm pulling these quite distal. I'm going to take my quad pro. In this case we're using a size ten. We've marked the end of the Quad Pro with a purple marking pen. And that's going to give us the postage stamp. And I'll start that basically on the superior pole of the quad. You can see in there I'll take the 15 blade knife back. Thank you. And then the pickups, then the Alice. And then one of the pearls here is to stay on the inside of your mark so that you don't harvest too big of a graft. And I do a full thickness harvest. I'm harvesting this right off the superior pole of the of the patella, and I'll actually take my knife as far as my incision allows before I start with the Quad Pro, and then we'll use our suture tape fiber loop next. And sometimes there's a little synovium underneath. So you just have to try to get that away with the knife. So we use the 15 blade as mentioned to harvest the graft from distal to proximal as far as my incision allows. And then we use the quad Pro to finish it up. Here we'll prep the distal aspect of the quad with the fiber loop. And you want to get this nice and tight because this is what's going to be going in the quad Pro. So we have the quad Pro harvester. We'll take the needle from our fiber loop and put this in the tip. And we'll use the weight of the needle to just fall through the harvester just like that. And then this quad pro can be used. You slide this along the quad for as long as you've harvested, and then you're going to go in 360 degree loops either clockwise or counterclockwise. And it's a push pull fashion. Staying parallel to the shaft of the femur. So you can see it's nice and calibrated. Here. I'll turn that up. And my goal is a 65 to 70 graft for nearly all of my patients, from five foot 2 to 6 foot two. If they're a little shorter, I go a little shorter. If they're a little taller, I go a little longer. And then I'll take the graft, keeping it in the window of the quad Pro, pulling the needle back, and then we'll move the Quad Pro without spinning now up because we've already done our cut. And you can see calibrated here. We'll go ahead and take the pushrod insert this in. And again I'm going to do a double check here on the calibration. Make sure I really like it. And I'm holding firm tension on the quad. And I'm doing a push pull. And I like that sound. And when this comes out this should be a nice full thickness graft. Not getting into any muscle a little muscle is okay. But you can see here this is really a nice full thickness harvest. You can see all the layers to the quad. So you can see that that full thickness harvest has been completely closed with the loop link, which again is a very strong luggage tag suture and it's very low profile. This is not going to cause any irritation to the quad tendon. This is not going to cause any irritation or adhesions to the patient. And you can see it's completely closed and there's no gaps whatsoever. So we won't get any fluid extravasation throughout this. You can see the VMO quite nicely. So really nice mid third quadriceps tendon harvest with closure. So here we have the completed quadriceps graft. Again all soft tissue about 65mm in length by approximately ten. Or in this case about nine nine and a half by circumference. And we use this all with all of our instrumentation. We harvested this all and prepped this all. So you can see the only difference here with the fibre tag tightropes is this now has the soft button. So those are the yellow buttons. And you can see those on either side. And we can see this is the femoral side. Because of the internal brace, the tibial abs side will not have the internal brace. And again these yellow portions here are what's new. This is the soft button. All suture. No metal no plastic no peek. Incredible opportunity for us to have a metal free construct for our ACL reconstruction and leave patients with a more natural knee. So now we're going to go ahead and get the graft and the graft tubes to compress it down while we get ready to drill our tunnels. So here now we're compressing the graft typically on the back table. And it's in the graft compression tubes. And we'll try to get this as tight as we possibly can so that we can make this graft as compressed as possible. Taking advantage of the quad, with its full thickness nature and the circumferential fibers, we get a nice cigar like graft, but we want to keep it as compressed as we can. So here's our flip cutter femoral guide. And we can see what's new now is we have a ten millimeter step at the end instead of seven millimeters, which makes this a lot sturdier in the bone and a lot easier to pass our soft button with respect to our fiber tightrope, we have the femoral guide in. So we'll use our flip cutter for our all inside. This is the new power. Okay. So we'll mail it in the ten millimeter step. And then we're going to open and flip. Nine five okay. And the reaming has gone all the way back to the step. And again with that ten millimeter it's just a three millimeter difference. But it provides you just enough to be able to do that without compromising the cortex, which is really nice. It's a really nice addition, small tweak, but big difference. Why don't you take a look at that and we can see our socket and then we can see our step right there, which is really nice. Really nice. All inside ACL femoral socket. So we'll go ahead and pass our snare. We'll retrieve it. Good. All right. Here. We'll take the Apollo just to demonstrate that we've marked our spot for the tibial tunnel. Tibial tunnel. Posterior aspect, anterior horn, lateral meniscus. Use the Apollo to burn that off. We'll get our flip cutter guide. For the tibial tunnel. Good. Perfect. We'll take a mallet. And again, we're going to mail it in this the new bullet here that has a ten millimeter step, which is going to make it super stable in that cortex. And then we don't have to do any math. So we'll go ahead and open the flip cutter to a 9.5. And normally I get about a 25 to 30 millimeter socket. But you don't have to do any math here. And we're just going to ream back to the step. And we're reaming just till we feel that tip of the step so that we know that we're safe on the cortex and we don't have to worry about breaching the cortex. So we'll go ahead and put the snare up and we'll retrieve it. So we'll go ahead and grab the suture snare. And I really like these snares. And it sounds a little corny, but the colors are really nice because they're contrasting the black and of course, the blue. I'm going to switch my camera to the opposite portal. I'm going to go ahead and grab my snare out the opposite portal from the tibial tunnel. Then I'm going to switch my camera back to lateral. We'll go ahead and put our passport in to help with graft passing. And then you've got the tibial side. And then we'll go ahead and get these both out the portal here. So the blue and white is for the femur. The black is for the tibia. Perfect. Okay. Good. And now we're ready for graft passage. So we're going to want to lengthen our tightrope. But you can see here the soft button is a little bit squished. So to get that nice and elongated to make it easier for passing into the socket, we're going to pull the opposite limbs of the the included tiger wire and the fiber wire. And you can see here how that goes from a ball to a nice oblong or even linear shape. To make this easier to pass through your 3.5 hole. Then what we're going to do is lengthen our tightrope. And if I want to lengthen this side here. So we have this side and this side. If I want to lengthen this side I'm going to hold on to the opposite side. Just like that. And that'll prevent this from getting. Bunched up. And then I'm going to go to lengthen the other side. And so now I'll hold the blue sutures the fiber wire. And then we'll go ahead and take the slack out like normal. And that's nice and elongated. Now we can mark it. And again, you can see here even doing that I bunched up the soft button again. So I'm going to take my tiger wire and fiber wire and pull those and elongate the button again to make that easier for passing. So I'll mark the graft here at 20. And usually the way we prep the fiber tag tightrope, it's at 20. But we'll do it. We always measure just to make sure. But yeah the end of the suture is usually right there. And if you can get 15 to 20 in each socket, you'll be perfect with a 65 or even shorter graft length. All right. So we're going to go ahead and mark our interosseous length. And we're calling that about 40. I'm going to put a dot there 3540. Good. And that's on the this is on the femoral side okay. So now we're passing our graft again. This is the internal brace side of the soft button fiber tag tightrope. But we're not going to pass the internal brace that's going to be remaining with the graft. So we're going to go ahead and pass. We're pulling on opposite limbs. The tiger coming out the medial portal and the blue coming out the lateral femur to keep the button elongated. And we're going to pull until we see our marking and kind of feel the button flip against the lateral cortex, which we just felt. And now we're going to make sure that we don't have any tension. And then now we're going to check it. And we are pulling like crazy on the IB. And I'm going to give the graft a little tug. Okay. So we're hooked against the femur. I'm going to give the ibz a little tug. Good. So you can see I'm pulling pretty hard actually. And that soft button is now bunching up against the cortex. We're going to hold tension on the IB, and we're pulling out the lateral femur on the tightrope. And we're going to shuttle about 15 up. Good I would stop there. So we have our graph passed in this femoral socket. We're going to pass everything into the tibial socket except for the tiger wire that's in both the femoral soft button and the tibial soft button. So we're passing everything, including internal brace, but we're not passing those new tiger wires because we're using those to keep the button elongated if we need. We're going to go ahead and shuttle this into our tibial socket. Okay. So now we'll go ahead and elongate by pulling the tiger and pulling the blue. And we're emphasizing here even through the whole tibial tunnel which has a turn here. I can pull on these to make that button nice and elongated. And you can see that here outside. We're going to go ahead and pass our graft into the socket. Good. And we're dunking that down. Let's give it a nice hard pull if we can because we're not quite in yet. Now we can take out our tiger wires that are in each of the buttons. So here's the one on the tibial side. We'll go ahead and just pull that out. It's served its purpose. And again its whole purpose was to keep that button elongated, to get it through the 3.5mm hole from that flip cutter bullet. And now we no longer need that. And same with the femoral side. So that one's been removed. You can see our ACL graft. Looks nice actually looks really nice. Looks really low. That's where we want it. And now we're going to go ahead and tension on the tibial side. So what I like to do here is we'll go ahead and cycle the knee. So we'd hold tension on the graft I got this. We'd go ahead and I'll take the scope out. We would cycle the knee while holding tension on the graft. We cycled about 15 to 20 times and then we get the knee nice and extended. As you can see our button here, we'll take a hemostat. We'll put it in the tightrope just to hold some tension. And then we're going to take both limbs again with the knee in extension so we don't over constrain and we'll start tensioning down our tightrope. You can see the soft button is already starting to bunch up. And I'm getting that oh that's nice nice and tight on the tibia. And then I'm going to move these out of the way. So we're going to go ahead and fix our internal brace with a swivel lock suture anchor using our power. We're going to pass our internal brace sutures through our anchor. And you can see here we've got the knee in full extension. That's really important step. And then I'm pulling tension. And then I'm just going to let it dunk right in. And then we'll go ahead and mail it this in. So then what we can do is what I like to do is I'll actually put the scope back in and I'll take a look at the graft and then we can retention. And I like to do my graph tensioning last. And what we can do here is we can see do we want to do a little more tension on the femur or tibia. And I'd like to do the femur here. So we'll get the leg back in extension. Good. Just like that a little less extension. Good right there. And then we're going to go ahead and tension retention. Look at that. We can see we're getting a little bit of creep out of here which is awesome. Good perfect. And we'll come back down to resting position. And now our graft is complete. This is rock solid. This is something I'd be happy to have in any one of my patients. And I would be very confident that they'd be able to fully return. I mean, I'm literally pulling on this. This is awesome. The other nice thing about this is there's absolutely no metal within this construct whatsoever. When they see their x rays, they're not going to see any metal in their knee. They're going to feel like this is a more normal graft. This is a more normal knee and we know that the psychologic, the mental and emotional part is just as important as the physical and biomechanical part. And all of this is incredibly strong, incredibly biomechanically robust. We're going to have a great final product. Okay. So we can see here our final fixation with the soft button. We can see that the soft button is really conformed nicely against the anterior cortex of the tibia here. Incredibly low profile. Again no metal no plastic. Really going to be a nice a nice final result for the patient. And then if I move the tightrope tensioning limbs out of the way, we can see that the internal brace Fibertape sutures are going nicely down into that swivel lock suture anchor again, nice and compressed against the bone. And we have this beautiful low profile, metal free, all suture construct for this all inside ACL reconstruction.

All-Inside Quad ACL Reconstruction Using the FiberTag® TightRope® SB Implant With the InternalBrace™ Technique

The DualCompression hindfoot fusion nail creates a stable fusion site by providing two modes of compression for intraoperative and postoperative dynamic compression across both joints.

DualCompression Hindfoot Fusion Nail Demonstration

The Arthrex dual compression Hindfoot nail mechanism demonstration with a distal calcaneal screw and the distal tibial screw already inserted. The t-handle is attached to begin tensioning the dual compression mechanism. As the cable is tensioned, it pulls the dual mechanism slider distally until the joint is fully compressed. When the joints can no longer compress, the nitinol element begins to stretch and continues to stretch until the distal slider reaches its final position in the distal slot hears the compression sequence again in slow motion. Once it has been fully seated, the second posterior to anterior calcaneal screw is inserted to lock the distal slider in position and maintain the compression across the joint. An optional Taylor screw is then inserted to provide rotational stability of the talus. An optional second proximal tibial screw can be inserted for additional support proximally.

DualCompression Hindfoot Fusion Nail Demonstration

The Synergy Power™ system is redefining versatility, reliability, and performance in ambulatory surgery centers (ASCs). From streamlined workflows to unmatched power, learn how this system can transform your ASC.

Empowering ASCs and Beyond: The Synergy Power™ System

Empowering ASCs and Beyond: The Synergy Power™ System

Randy Lovell III, MD (Grand Rapids, MI), demonstrates the entire process of performing an endoscopic carpal tunnel release in the office under local anesthesia. He shows his local injection technique, reviews the NanoScopic™ release system’s benefits, and demonstrates his closure technique.
Video timepoints:
0:00-5:40: Administration of local anesthesia
5:40-8:50 : NanoScopic Release System review
8:50-15:15: ECTR procedure under local
15:15-16:25: Closure

Randy Lovell III, MD (Grand Rapids, MI), demonstrates the entire process of performing an endoscopic carpal tunnel release in the office under local anesthesia. He shows his local injection technique, reviews the NanoScopic™ release system’s benefits, and demonstrates his closure technique.
Video chapters:
0:00-5:40: Administration of local anesthesia
5:40-8:50 : NanoScopic Release System review
8:50-15:15: ECTR procedure under local
15:15-16:25: Closure

Live Surgery: In-Office Endoscopic Carpal Tunnel Release Using the NanoScopic™ Release System

Okay. This is doctor Randy Lovell, and we are going to take you through the numbing process for a wide awake local anesthetic. No tourniquet. Endoscopic carpal tunnel release. This first portion is going to be simply the preparation phase and the local anesthesia phase. So we're looking at a left wrist. I begin by palpating palmaris longus. Most of the time it's pretty easy to feel. In this case, she's got a nice FCR and a palmaris longus right there. I try to just straddle palmaris. That tends to be a really good radial starting point and then head towards the FCU, but I don't necessarily reach the FCU in terms of proximal distal, anywhere from five millimeters to a centimeter proximal to the wrist flexion crease is going to is going to work. And then I also map out Kaplan's cardinal line and the radial aspect of the ring ray. And even though we're not doing anything up in this area, these are nice reorientation Landmarks, if you will. When you're in your loops and the case is proceeding, it's nice to have something that you can quickly reference in case there's movement or something shifts. You can always quickly reflect whether through your loops or around your loops, to know that you're, you're in a safe spot and doing the right thing. So the marking is done. Just a little bit of alcohol on the skin, and we use ten millilitres of 1% lidocaine with epinephrine 1 to 100,002 total pokes. First poke I've already prepared the patient. It's kind of like a three out of ten in terms of pain. Bunching the skin up pulls the skin away from the nerve and gives you a nice target to shoot at. Poke three. Two one. Good job. And I don't move the needle. It's a 27 gauge needle. It's just in the sub-q space. So it's below the skin, superficial to the antebrachial fascia. And I like where the medication's going in this particular case. If it's ever moving into an area that I'm not happy about. I rather than use the needle to do it, I simply will use my free hand and massage the the fluid back where I want it. Kind of like a tube of toothpaste. It's a much more comfortable way to manipulate the fluid without using your needle to redirect it. Okay, little break here. And so needle comes out. That's the worst part. She did great. And you can see this is about what you want to see. Kind of a raised area that that encompasses your entire incision. And if you're going to hedge it one way or another, a little bit on the proximal side is a good way to go. And then I just sort of massage it in. That tissue is rapidly getting anesthetic so that when we add additional medication or that second poke if you will, should be painless. The patients also been prepared that she may feel some pressure building up in her palm. And if it's ever too much to let me know and I simply stop adding medication until it becomes numb again. But it's a very effective block. It is a block that you could very easily do an open carpal tunnel with very easily. It's by far the most tolerated and comfortable block that I've experimented with doing local anesthesia, endoscopic carpal tunnels. The local is not in the carpal tunnel. It will sit as you're about to see. It sits superficial to the transverse carpal ligament, but deep to the skin of the palm. And this is about what you want to see. Some are already starting to see some blanching from the epinephrine. Here comes the second poke. And this begins again in the form where she's where she's numb. She will not feel this poke. And then once we're in, in the right plane, I keep the needle very low. And we are just slowly adding medication. Doing okay? Okay. So what I want to see is This little rise right in line again. This is another good reason to have that extra marking is I just want to see ultimately sort of a rectangle. Overlying the carpal tunnel proper. You doing all right? Yeah. It just feels weird. Weird, but not not super unpleasant. Okay. And again, we're just pushing in very slowly. I don't advance my needle until I know that there's some medication out in front of it. And it's just going in nice and smooth. The fewer times you move your needle, the better. The patient has no sharp experience with that needle. It's just sort of a pressure phenomenon at this point. Almost done. We got about one milliliter left. But ten I have found to be more than adequate. Quit. And that's it. Excellent job. The hard part is done. But you can see this is you could absolutely do an open carpal tunnel right here if you needed to. And then the next critical step is time. You need to give this bloc at least 30 minutes. But during that stretch the patient is free to sit up, move around the room. If they have family with them, they can they can just sit with them and chat. These two kits have already been dispensed sterilely, so we'll do the unboxing of both of them. I'll give you that first first kit has the actual center line device, which is this handpiece here. It's very lightweight, but it's lightweight and also very sturdy. It handles very well. It remains light because the camera that we put into it is also extremely light. So it's maneuverable, Durable, very light, but also it's very stiff. There's no sense of flex or flimsiness to it. So in that regard it's been very nice and easy to learn and control. I also really enjoy the fact that the the housing is clear. And so the view when you're performing the procedure, you can not only see at the end where the work is being done, but you can also see to the sides, which adds a huge layer of safety as well as eases the learning curve a bit. So that's the centerline device there, a very nice two function instrument here on one end, a little bit of a spoon apparatus, which is used to remove the synovium from the undersurface of the transverse carpal ligament. It does a great job of that. And you'll see that in action. And then on the flip side is a classic dilator which which helps give the a little more room for the device. Box number two. Also sterile. Sterile packed has the Nanoscope and it is just a single device. Leave the cap on. That is for calibrating before the case begins, and you'll see that in just a second. And it's just a single cord. It plugs into the monitor which the current iteration is basically the size of a laptop. And we'll pass that off. So we just simply take that plug it in saying connecting. So now that we're plugged into the monitor looking back at the camera, we keep the cap on for calibration. Hit either button one time and it takes about five seconds. And the calibration will complete here in a second. All right so that's done. We've got plenty of cords. So you got a lot of flexibility in how you set your room up. Now at this point we can pull the cap off. There's your camera. This just simply inserts into the center line. Underline. And there's a little bit of a twist and a snap at the end. If you orient the flat side of the nanoscope vertically or I guess away from the palm, and that orients your view on the monitor properly. And that's it. That's it for setup. The trigger. We didn't talk about that. The trigger on this device is just a little spring device here. And. And when you push that down, the blade at the very tip is deployed. When it's released, it's safely protected inside the housing. So we'll just set that aside and we'll get going. So now we're back looking at the left wrist here, these are markings from before. Patient has been anesthetized for right around 30 minutes. You can really see this white shadow or halo which is consistent with the epinephrine causing blanching. And so you can see that the carpal tunnel itself is widely anesthetic simply from the markings there. And then obviously we're numb here too. We'll check that up on your forum. I'm going to give you a little pinch. Do you feel a little poke there? Okay. Do you feel anything sharp or pokey here, here or here? No. Okay. Movement touching pressure is going to be normal. No pain. All right. We'll get started. Occasionally we will. There's venous structures traversing this incision. And it's almost impossible to completely avoid them. But the epinephrine helps. And skin retraction really helps. So at this point it's just simply mobilizing the skin. And we're working our way gently down to the antebrachial fascia. More often than not, you can see your palmaris longus. Longest. And if we get that in good view, that's a really good spot. To place your retractor there. In there. So that's great. And. What we're trying to see is the tight white fibers of the antebrachial fascia. We simply grab small amounts of it away from what would be the nerve and make small little openings, and eventually you'll see a little rent. And I'm not sure if that shows on the video, but there is an opening. Now, if we get in there and do one good spread there, I'm looking right at the median nerve. It's right there. Thus far we've not made any contact with it at this point. I like to hang on and do a little spreading below the fascia, a little above. And at this point we can see safely in the midline and we release released approximately under direct view. Shift our attention to the distal edge here. It's really important that you don't release this too far at this point, because you can sometimes lose your handle, if you will, and stay there for a second. Come on out so that those prongs are are facing away from the nerve, and it's controlling that leading edge. And then at this point, I as the surgeon, I like to hang on to this. Your assistance will frequently try to take this out of your hands. But I like to hang on to this because it keeps me connected to the patient. Wherever my hand goes, she's going to go. I also place my finger directly over the path of the carpal tunnel release. This gives me a second, a second point of safety, a second point of control where I know exactly what's happening, that I'm in the right spot, I can, I can, I can see what I can see, but that gives me a tactile feedback that we're in the right spot at this point. We go to the elevator with the tip oriented upward, and I try to engage. As soon as I'm past the the skin hook, I try to engage the ligament and just small little pushes and work my way in. And until I feel sort of a nice, grating washboard sensation, I'll also drag the device in an older direction and I can feel the hook, the hamate. And that way I confirm again that I'm in the right spot. Flip it over and we go to the dilator pressure here. Okay. And we're just about done. So at this point this comes in low. I prefer an overhand grip. I typically use my thumb. I think some guys like to use their fingers. This comes in real low. Again. It engages that leading edge. As soon as I'm there, I'm lifting up against the ligament, which helps keep things from getting in the way. And at this point, my eyes are fully oriented to the monitor. So we're entering in to that space, and we're seeing very clearly the transverse fibers of the ligaments, very tight little pressure. You're doing great. So when I see that and there's no response from the ligament, I know I'm just past it and I'll release I'll release about half of it. But she's still pretty tight in there. Now we can start to see some separation. And what you can't see that I can feel. I'll leave that muscle alone. So the healthy muscle I'm going to leave alone. We're already fully within the release ligament, and then I'll just re-engage the ligament the rest of the way, and we'll do a final double check, and we'll come back in. And what you can see, because the housing is clear, you can see radially, and only that the ligament is completely released on both sides. If there's still some white fascial bands, I'll, I'll generally try to release those if there's. But obviously we're extremely decompressed at this point. Leave the muscle alone. One other comment is we've been in this space now for a bit. Normally you wouldn't, but there is absolutely no fogging. So there's no interference of your view because because of the nature of the device, you do not have to apply anti-fog or anything, and there's just no misting or anything interfering with the view. It's it's clear as can be. And we're done. How'd you do? You're good. Yeah. All done. You did great. So closure can be whatever you like. My preference is, in most cases, a subcuticular in a somewhat traditional fashion. I do leave the two ends out and I tie them together. And it's it's been very effective, a very effective closure. And I like just a clear, occlusive dressing. This allows the patients to shower right away. As long as the plastic is adherent, they can shower immediately, which is a nice convenience for patients. And we'll do an ace wrap. Patients are allowed to remove this at their desire. But I do like a little just a little compression. Keep some swelling down, keep some bleeding down. And and then the patients don't have to look at their incision. But lots of people decide to take this off after a couple days or day one. That's fine too. It's really what the patient wants to do.

Live Surgery: In-Office Endoscopic Carpal Tunnel Release Using the NanoScopic™ Release System

At the Orthopedic Technology and Innovation Forum, Matthew T. Provencher, MD (Vail, CO), presents a discussion on surgical reconstruction options for glenoid bone loss, highlighting modern algorithms for autograft and allograft fixation.

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Autograft and Allograft Fixation Options for Glenoid Bone Loss

OrthoPedia: Autograft and Allograft Fixation Options for Glenoid Bone Loss

Carl T. Hasselman, MD (Pittsburgh, PA), demonstrates the effectiveness of the ApolloRF® SJ50 probe in various ankle procedures. Dr. Hasselman highlights the probe’s benefits, including low default settings, optimized aspiration, and 50° curvature.

ApolloRF® SJ50 Probe in Ankle Arthroscopy

Hi, I'm Doctor Carl Hausmann. I'm from the University of Pittsburgh in Pittsburgh, Pennsylvania. What we're going to do is we're going to go over ankle arthroscopy with the use of the Arthrex S-50 Apollo probe. So I put my curve, the tip of my probe, 90 degrees into the joint. And then I lift my hand and it just goes in very quickly and easily. And that keeps you from struggling with the probe. Because once the probe is in, it will do the work for you. It also has hand control. So you'll have blue, which is just like on most instruments. It's going to be your coagulation and you're going to have yellow which will be kind of your cut and rapid cut. It comes with factory settings. I can tell you right now, 98% of the time the factory settings are more than enough to accomplish everything I need to do. But the nice thing is, is you can actually increase or decrease the intensities from the factory setting on the probes. With this probe at the factory setting, it really takes a matter of a second, and you can get a lot of this tissue out of the way. The neat thing about this is you'll notice it has the suction, so that if I do get an air bubble or two, it quite quickly alleviates them. And that's what I like about this probe more than the others. And so the nice thing is this thing is keeping the area cool while I'm doing my ablation of that area. Most probes, as they're straight when they come in, that's what you're going to get. So you're going to actually have to take your hand and bend your probe. And most of the probes are too stiff. So you end up using a pair of pliers or something to bend it. Then you ruin the sheath on the probe. You end up throwing them away. This probe has that hook so you literally can come in. And then when you rotate it, actually look at that. It matches the shape of the talus. So it is designed to let you go back all the way to the back of the ankle. And you can see I am literally basically almost at Subtalar joint. I'm so far back in the ankle. In fact, there's the posterior tibiofibular ligament. And you can see this probe can get all the way down to the posterior part of the ankle. So if you're trying to get an Ars trigonum out arthroscopically, I am literally right where the eyes would sit. So you could actually do your complete synovectomy with this probe and you can get all the way back. The other beauty is that two things of this probe, it actually has a 360 degree cutting edge on it, which is quite nice because you can actually use the edges just as much as the surface to do ablation. So one of the things you can watch is if for some reason you wanted to take down one of the ligaments in the back, I can literally put it in there and I can actually just hit and you can see that it's starting to actually cut using the edge of the probe. And you can see how I'm already starting. I'll go in close. You can see how the edge is literally cutting the ligament for me. But at the same time, if I didn't want to cut the ligament, say it was just hypertrophied and thick and frayed. I can also use my COAG. And if you watch when I see these frayed edges, I can literally just use my COAG and it will just get rid of the frayed edges. So it's basically getting rid of those frayed edges without really damaging the fibers, because you can see the see the fibers are still not hurting or not being damaged. They're staying perfectly nice. Now, for example, in arthritis, a lot of times we all see this shag carpet appearance and you want to get rid of this, but you can literally take this probe, putting it on COAG and just kind of come in and clean those areas up and see how I can just nicely get rid of that shag carpeting by kind of just mowing along it. But if you look down at the cartilage, you'll notice that I really haven't damaged the cartilage in any way. My probe is now between the anterior capsule of the ankle and the anterior edge of the tibia. And very commonly, we want to get rid of all the synovitis if we're doing an anterior colectomy. And so the beauty of this probe is you can actually get right up in that area. And then with my probe on cut, I can literally clean this whole area up. The one thing I have found is that a lot of times I'll give it a second breath after about 5 or 6 seconds, I'll like take a one second just to let the aspiration get rid of any warm fluid. And that way I can keep the whole joint space nice and Nice and cool. So I'm at the anteromedial gutter of the ankle. There's going to be some fibers of the anterior deltoid that I can clean out. But you can see, I can rapidly clean out all of the tissue in the anteromedial ankle. And the other nice thing about the probe is when I'm in here with this probe is because it's hooked. One of the other things I can actually use is use the hook to my benefit. So I can actually come in, and I can hook that tissue and pull it away from the cartilage surface. And once I have it pulled away from the cartilage surface, then I can hit my cut and I can actually cut the tissue. And that way I'm really staying away from my articular area so the hook actually can use it as an advantage, just like a nerve hook to get rid of this tissue. If you're getting nervous that you're getting a little too close. Now, what I could do is if I wanted to get rid of this, I could literally use my probe because of that hook, and I could breed all the tissue around it quite quickly. The nice thing is, I can respect that cutting of the 360 cutting. You'll notice how I'm literally taking off this tissue right around it, and not a single bit of damage to the lateral wall or the medial wall of the talus. And so I can ablate this. And I can also use the hook action to pull it away in a blade. And you can actually see how I've completely loosened this. So the neat thing is, is I've done a complete using the Sf50 probe. And now I'm just going to use one of the Arthrex Graspers. And I can come in and literally grab that piece. And the thing is I can pull it out. And now there's just a small piece left. And I'm not going to belabor the point, but you can see how easily I did that. But the really neat thing is with that probe is I just put this in and I'll pull the tissue back and we'll look. You do not see any damage. We did a complete synovectomy and Dyneema of the medial gutter. And there's not a single burn mark, not a scuff mark, not a single mark on that talus showing you that the probe didn't hurt the articular cartilage in any way, shape or form. And that's really neat about this because you literally just took out all that synovitis, and there's just a small piece of that medial malleolus left. This person has a cartilage lesion and it's an anterior lateral OCD, which is not uncommon. So a lot of times after we've done our microfracture, a lot of times we'll have those edges. This is the other place the ss50. So now you've microfracture you're quite happy. But you'll notice one of the things that we have left now is we have this rough edges right in here, and we worry about those breaking off. A lot of times people will put a shaver in, but this is actually one of my favorite tricks, is you can actually bring the ss50 in. And with the COAG just slowly, gently hit these areas and it actually kind of just takes off any of the rough edges. So just using the probe and little blasts, I can clean up any of those rough edges. But I'm not hurting the cartilage. Some of the key tricks to remember one. When you're inserting it, always insert the probe so probe so that the tip goes in first at a 90 degree. So you notice how my hand is held. So I'm going in first. Then I rotate my hand. Don't try to go straight in. It's not going to work because unless you want to make huge incisions it's not going to work. You want to keep your incision small, put the probe in, get into just the edge of the capsule, then rotate your hand. It comes in quite quickly. Number two respect the curve. Remember, when you're going back into the back of the ankle, you have to keep it turned at a 90 degree only as it goes past the talus. Then I rotate it and it respects it. And so now I can go into the back of the ankle and I'm in the back of the ankle. I can do all my work. And that actually is the safety probe and a lot of things I like about it. Again, I have that COAG function works great for osteochondral lesions, and you'll ablate it within a matter of seconds. And it's beautiful. It saves you a lot of time. And that's kind of the reasons, all the reasons that I like this probe because it has all the functions you could possibly need.

ApolloRF® SJ50 probe in Ankle Arthroscopy

Sohrab Gollogly, MD (Monterey, CA), demonstrates the transforaminal epidural steroid injection technique for the endoscopist who wishes to use the same technique for targeting and localization of transforaminal endoscopic spine procedures.

Transforaminal Epidural Steroid Injection for the Endoscopic Spine Surgeon

My name is Saurabh Gallegly. I'm an orthopedic spine surgeon in Monterey, California. I specialize in endoscopic spinal procedures, and today I'm going to demonstrate the transforaminal epidural steroid injection technique that I use for the Endoscopist, who wishes to use the same exact technique for targeting and localization of transforaminal endoscopic procedures. We're going to begin with the patient in the prone position on the operative table. We'll take an orthogonal AP X-ray with a radiopaque marker across the intended disc space, and will align that marker with the midline of the disc space as seen there of the L4 five level. We'll draw that line on the skin and then we'll swing to the lateral projection. Once we've moved the fluoroscopy unit from the AP to the lateral plane, we will align the fluoroscopy unit by imagining a line from the center of the source, coincident with the line drawn on the skin to the center of the detector unit. We'll take a lateral x ray, and that generally corresponds with a perfectly aligned orthogonal lateral x ray of the disc space in question, centered in the center of the fluoroscopy field of view. And next we'll find our starting position by compressing the skin on the patient's flank, identifying a spot Art as seen here, where the tip of the radiopaque marker is two facet widths posterior to the facet complex in line with, in this case, the l45 disk space, and that generally corresponds to a distance of 10 to 12cm from the midline, depending upon the sex, stature, and shape of the patient. After identifying the starting point, we'll appropriately prep the skin with a chlorhexidine or alcohol prep. We'll use a small amount of local anesthetic in order to raise a wheel in the skin. After the skin is appropriately anesthetized, we'll introduce a spinal needle in the starting trajectory, and after puncturing through the skin, we'll follow the same line drawn on the skin, using the fluoroscopy as a reference mark in a slightly more shallow angle than anticipated, until we dock on the lateral aspect of the complex as seen there. That fluoroscopy picture shows that this spinal needle is on the dorsal lateral aspect of the facet. So we'll back the needle up and we'll raise our hand in order to go more ventral on the facet picture there. We're now at the midpoint of the facet joint and lined with the disc space. We'll back up a little bit more. Go a little bit more. Ventral here. Picture there. Just about through here to the disc space. One more slight raise of the hand here. Picture there. And we're in the foraminal space. The tactile feel that confirms that you're in the correct location is you'll feel a slight pop as you skive off the facet joint through the facet capsule into the foraminal location. And as we swing to an AP view, now we can confirm that the tip of the spinal needle that we are indeed just lateral to the mid line in the real world, the needle is now safely positioned in Camden's triangle. The traversing nerve root is medial to the tip of the needle. The exiting nerve root is superior to the tip of the needle. And if we were to inject a CC or two of the appropriate steroid plus local anesthetic, we would get a transforaminal epidural steroid injection in the exact same position that we would introduce the endoscope. In this instance, for demonstration purposes, we're going to inject a CC or two of Omniview in order to outline the traversing and exiting nerve roots, and demonstrate the placement of the tip of the needle.

Transforaminal Epidural Steroid Injection for the Endoscopic Spine Surgeon

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