The knotless anchor products are used in a variety of procedures in the shoulder (e.g. rotator cuff repair) as well as scapholunate repair and UCL (Ulnar Collateral Ligament) repair. The unique PushLock design allows the surgeon to adjust the amount of tension on the tissue intraoperatively, allowing for precise tissue reduction. The tissue is securely held in a knotless fashion, allowing for soft tissue healing to bone. The anchor is available in bioabsorbable (PLLA), BioComposite and PEEK.

Hand and Wrist

Product

Optimize tensioning and fixation without knot tying. The 2.5 mm PushLock suture anchor provides a secure means of knotless fixation in the hand and wrist. Accommodating up to 1.3 mm SutureTape suture, this 2-piece anchor enables a no-profile repair that is quick and straightforward.
 
The 2.5 mm PushLock suture anchor uses a PEEK eyelet to place the sutures at the bottom of a drill hole, allowing precise tension and the ability to lock the sutures in place by impacting the tack portion of the anchor. Both the high-strength radiolucent PEEK and the bioabsorbable BioComposite (PLDLA amorphous copolymer and beta- tricalcium phosphate [ß-TCP]) PushLock optimize tissue tension and fixation without knot tying.

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Human

2.5 mm PushLock® Knotless Suture Anchor

Steven S. Shin, MD, (Los Angeles, CA) demonstrates an open triangular fibrocartilage complex (TFCC) repair using FiberWire® sutures and a Mini PushLock® anchor. The Mini PushLock allows for a knotless, zero-profile repair down to the ulna.

video

Open TFCC Repair

My name is Doctor Stephen Shin. I'm a hand surgeon with the Kerlan-jobe Orthopedic Clinic in Los Angeles. I'm here today to demonstrate the open repair of the Tfcc. Here we have a right wrist. First, I'll perform a simple diagnostic arthroscopy using two portals. The first portal is A34 portal right here, just distal to the Lister's tubercle. The second portal is the six R portal. Just a radial to the tendon. We'll just mark our portals right now. Then using a number 11 blade, make my longitudinal incision. And then use a mosquito clamp to dissect down to the dorsal wrist capsule and then pop right into the joint, which I've just done. Now we'll do a simple diagnostic arthroscopy. We're starting here radially at the radiocarpal joint, we see our volar radiocarpal ligaments. We'll now move only. Here's our scapholunate ligament. And here is our articular disk of the triangular fibrocartilage complex, our tfcc. So we'll go ahead and now insert the cannula. And while I'm holding the cannula we'll remove the trocar. So here is the cannula in place. And as an option you can use this small wrist cannula for your tfcc repairs. In this case I'll remove the cannula. I'll insert a probe at this time just to evaluate the articular disk. Here's our tfcc here. We'll now do a trampoline test with our probe. Not bad. No obvious central tear. And now I'll stick the end of the probe peripherally underneath the tfcc. And actually, she does have a peripheral tear of the articular disc. So you can see the increased laxity here as I'm kind of pushing up on the disc. So we finished the diagnostic arthroscopy. And now we'll proceed to the open repair of the tfcc peripheral tear. Proceed to make an incision right over the ulnar styloid and head just ulnar to the ECU tendon. Go ahead and retract our tissues. We'll continue with our incision through the retinaculum. Obviously you want to be careful of the dorsal under sensory branch. And now we'll just proceed incising over the ulna into the capsule. We've dissected down to the ulnar head, and Styloid performed our capsulotomy. And here is our peripheral tear of the tfcc. I have a two or FiberWire suture that I'll now pass through the tfcc. Will be performing a horizontal mattress stitch in the periphery of the tfcc. This will pull the tfcc down nicely back down to the ulnar foveal region. Each strand of the FiberWire suture will pass around the ulnar styloid as such, and then we'll use a PushLock anchor to dunk the suture ends into the distal ulna. Here's our drill for our 2.5mm PushLock anchor, just about a centimeter or so proximal to the ulnar fovea. Drill all the way down to the stop. We'll take our suture ends here that are passing through the tfcc. We'll cut the needle off and then pass the two limbs of the suture through the eyelet in the PushLock anchor. We've now passed the two limbs of the FiberWire suture through the eyelet of the PushLock anchor. We'll now place the eyelet into the Into the hole while pulling tension on the two limbs of the suture with the anchor down to the outer cortex of the bone. We'll proceed to insert the anchor. Into the ulna. Once that's done. We'll remove the handle. And assess the strength of the sutures, which is good. It's not going anywhere. And then remove the suture. Limbs. I repaired the peripheral tear of the tfcc using the FiberWire sutures and a PushLock anchor. You can see that it's nice and taut. I'll now proceed to repair the most peripheral edge of the tfcc, using the suture through adjacent capsule and Ostium a place at least 2 or 3 sutures to bring the peripheral edge down again on this side, grabbing some of that capsule through the most peripheral edge. And we'll just look at it again. As you can see, a very taut repair of the tfcc. We'll need to also perform a tight capsular closure, which is very important as well. The Tfcc is a complex of different structures at the ulnar side of the wrist, not just the articular disc. So it is important to make sure that all of these structures are closed tightly up here. I will more distantly grab both the retinaculum and the capsule dorsally. Here's our retinaculum here, and then we just proceed to place a few more sutures to close up the deeper layer. And then you can just close the skin and your standard fashion. I usually use an absorbable suture and a subcuticular fashion, and the incision heals very nicely. Postoperatively. I'll mobilize the patient in a sugar tong splint for 7 to 10 days at the first post-operative visit. I'll remove the splint and convert them to a Munster type cast. I'll continue mobilization for another three weeks for a total of four weeks of post-operative immobilization at four weeks post-operative. We'll begin therapy. Therapy will continue for approximately two months to regain range of motion and strength by about three months or so. The patient is back to their normal activities.

A new technique, presented by Dr. Richard Howard (St. Louis, MO), describes a knotless arthroscopic repair of foveal TFCC tears through an ulnar tunnel. Using Micro SutureLassos, Fiberwire suture is passed arthroscopically through the torn TFCC. The sutures are then tensioned through an ulnar drill tunnel and the TFCC is reapproximated back to its ulnar attachment. Pushlock anchors are used to provide low profile knotless fixation of the sutures in the ulna. The final construct results in a stable knotless repair of the TFCC back to bone using a reproducible and low profile repair.

Arthroscopic Foveal Reattachment of TFCC through an Ulnar Tunnel

So we do a TFC repair. We want to do it through A34 viewing portal. So this is a central radial sided tear. And there is your pre styloid recess. A couple of reference points I need to make is I need to know where the tip of the ulnar styloid is. And I need to know the anterior and posterior dimensions of the ulna. I want to shoot a pin at a 45 degree angle coming up into this foveal area. You can do that with a slam guide. You can do it freehand. So I just poke this in. So that's kind of pretty close to where we want to be. So we'll leave that in. We're just going to make an incision right over the wire. And when I when I do that, I'll just palpate the bone and make sure that I'm I'm centered. Then we're going to drill over the wire with a three millimeter cannulated drill. When we pass these sutures, the first pass, we're going to just take a 200 FiberStick and bend it over the tip like you see here. And as it penetrates, it will pop through the TFC on a real unstable TFC. I can kind of hold the TFC down and then penetrate with this parser. And this will be my most medial stitch. And it looks like it might be too medial. But you got to remember I'm coming in at about a 45 degree angle. So notice how I got to push down on the cartilage. It's a tight space, so it's hard to pass point. But you can spin this suture and it'll spiral itself above the TFC like a screw. And it leaves a nice big loop there. And then I can just pull back and that loop will stay behind. So I'm going to come a little more vertical this time and get this bite back here further. So now I'm a little more peripheral here. And I'm going to insert this loop and I'm going to retrieve both of these together. The advantage of coming out both is that I'm not going to get any soft tissue trap between the suture and my snare. So we come out with this, you can get fancy and thread it inside the joint. I do that sometimes if it's easy and fast, but I'll go ahead and load this outside. And then we're going to retrieve this down the cannula. Just putting a large mattress suture over the top of the tfcc. And again I'm docking that down into that three millimeter tunnel. And I'll clip that with a hemostat and toss it to the side. Then we'll load another FiberStick and I will make a cruciate right over the top. And again, I can do that little spin maneuver to push a bunch of suture into the joint. So my next one needs to go right over here to kind of form that cruciate pattern. So there's my fourth pass. And I want to feed that retriever there and grab these two and bring them outside the joint. So suture goes through the night and all loop retrieve that suture down. And now we have the mattress. Really stout repair pulling down into that tunnel there. It's stable. And when you have a patient who has some mild instability or even dramatic instability, you'll suck these sutures down. You can reexamine the patient, and it's impressively stable. So what we do now is we independently load these onto a PushLock anchor. It's very helpful to turn the water off when you're doing this step. I aim these up slightly. And remember, this is a stop drill. We can we can see our tunnel. We're about half centimeter from where these are exiting the bone, maybe a centimeter. And then we're going to load these onto the mini PushLock. It's kind of a push pull. Make sure we've got that really well seated. All right. Mallet. And you can over bury these things. You just seed it to the cortex. And I usually just cut these suture tales with a knife. Then we're going to load this onto a separate PushLock. So we've got two different anchors. Again get the tip kind of seated a little push pull. Make sure you got tension watching through the scope. Here we have two anchors. You can see they're coming down from this tunnel about a centimeter above into the ulna. You can see that these are really secured in there. Now, remember how I could lift that up before this is docked into that tunnel? Now, this critique, this a little this suture could have been a little tighter, but it's still docked down there. This one's better. But you see how they're crossing over. And I've got a good I can't lift that up anymore. So the post-op protocol would be that this patient goes home in a sugar tong splint in mid ProEAS supination, So thumb pointed at their nose. We have them then come back to the office in roughly a week. At that time, the therapist will make them a monster type splint, which allows them then to still flex and extend their elbow a little bit. But it blocks any pronation supination, and they stay in that for six weeks, and then they come out of the brace and start a slow, progressive program of motion, usually at six weeks after that. So they'd be three months post-op. Then we'll let them actually do strengthening and loading for somebody who's going to do weight bearing activities. I don't really let them go back to something like gymnastics, cheerleading, weightlifting for four months and have not had any issues with recurrence on that protocol.

Foot and Ankle

Anchor Insertion

Anchor insertion. The FiberTak anchor offers a low profile, reliable fixation point for ligament and tendon repair, with less bone removal and maximum pull out strength. Utilizing the K-wires and drill guide, pre-drill the cortical bone to an automatic stop on the drill guide, keeping the drill guide in place. Insert the FiberTak anchor and gently impact it until the handle is flush with the drill guide. After insertion, pull back the anchor inserter while holding counter pressure on the guide to bone. Next, remove the needles, rubber stopper, inserter and drill guide for final seating of the anchor. Pull the sutures back. This firmly sets the anchor in the bone. Reattach the tissue to the repair site with a SutureTape and secure for final fixation. The Biocomposite SutureTak anchor features a unique molded in suture eyelet that maintains its strength throughout most of the degradation cycle and eliminates suture abrasion during knot tying. The drill hole is prepared utilizing the appropriate drill guide. The anchor is introduced into the hole and the SutureTak anchor is advanced into the bone socket. Release the FiberWire sutures from the driver and remove the handle from the anchor. Reattach the tendon to the repair site with the FiberWire and secure with knots. The SwiveLock anchor offers a fully threaded knotless anchor design that provides maximum pull out and insertion strength while saving time. The drill hole is prepared utilizing the appropriate drill guide. The tendon is whip stitched with FiberLoop suture, and the suture is then loaded into the anchor eyelet. The eyelet, FiberLoop, and tendon are delivered into the bone socket while holding the thumb pad. Static. Twist the knob of the SwiveLock inserter to advance the anchor into the bone. The remaining sutures can be cut flush for a no profile repair. The 2.5mm mini PushLock offers a no profile Knotless TensionLoc suture repair. The drill hole is prepared utilizing the appropriate drill guide. Utilizing a suture first technique to capture the appropriate amount of tendon or ligament with FiberWire suture. The FiberWire suture is then loaded into the anchor eyelet and delivered into the bone socket. The construct is then locked into position by advancing the mini PushLock anchor body, creating a strong no profile knotless repair. The Corkscrew ft is a fully threaded titanium anchor that provides maximum fixation strength and simple insertion utilizing the included K-wires. Pre-drill the cortical bone to guide insertion. Thread the anchor into the bone tunnel until it is flush with the bone surface. Release the FiberWire suture and remove the handle from the anchor. Re approximate the tissue to the repair site with a FiberWire and secure for final fixation.

PushLock® Anchors

Child (D)

Bringing InternalBrace™ ligament augmentation repair technology to the hand and wrist, the Nano SwiveLock and DX SwiveLock SL anchors accommodate SutureTape and other biologic materials. The Nano SwiveLock anchor is used for repairs of the small bones in the hand and allows incorporation of SutureTape. The DX SwiveLock SL anchor can be used for repair or reconstruction techniques with InternalBrace ligament augmentation.

Steven S. Shin, MD (Los Angeles, CA), presents a thumb UCL repair with the InternalBrace™ ligament augmentation procedure using the Nano SwiveLock® and DX SwiveLock SL anchors.
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.

Thumb UCL Repair With InternalBrace™ Ligament Augmentation Using the Nano and DX SwiveLock® SL Anchors

Hi, my name is Steve Shen. I'm an orthopedic and hand surgeon from Los Angeles. I currently serve as Vice chairman of the Department of Orthopedic Surgery at Cedars-Sinai Medical Center. And I'm here today to demonstrate the thumb on the ligament repair with internal brace augmentation, using a nano SwiveLock anchor in the phalanx and a 3.5mm SwiveLock anchor in the metacarpal. So here we have two SwiveLock anchors that we use commonly for hand and wrist surgeries. On the top we have the 2.5mm SwiveLock anchor. This has a metal body and is suitable for using a SutureTape and suture, but not for graft. On the bottom we have a 3.5mm SwiveLock anchor. And as you can see, this is a peak body and the peak fork tip here. And with this anchor you can use a tendon graft and SutureTape. So that's these are the main differences between using the smaller nano SwiveLock and then the larger 3.5mm SwiveLock anchor. Here we have the kit for the nano SwiveLock anchor. As you can see there are two drill bits right here. One is for soft bone and one is for hard bone. We have our gray drill guide right here. So the color matches to the the gray color of the SwiveLock anchor driver handle. And here we have two guide wires that are placed first before you drill with the cannulated drill bits. Here we have the drill kit for the 3.5mm SwiveLock anchor. And as you can see here there's a silver drill bit. This is 3.0mm in diameter. And this is a gold drill bit that is 3.5mm in diameter. And the difference here is with the smaller drill bit you can use the SutureTape or LabralTape or whatever tape you desire. But this does not accommodate graft. So when you want to use a tendon graft you want to drill slightly larger with the gold 3.5mm drill bit so that you can accommodate tendon graft and tape with your SwiveLock anchor. And over here we have the blue Drill Guide. Again, the color matches the blue color of the 3.5mm SwiveLock driver. And then on the bottom here you have three guide wires that come with it. And the nice thing about these guide wires is it has a laser line here at the at the end of them. So you know kind of exactly how deep you need to drill your wire before you can just go and grab your cannulated drill bit. So now I'm going to demonstrate a thumb ligament repair using a nano SwiveLock anchor in the proximal phalanx. And then a 3.5mm FibuLock in the metacarpal. As you can see, I've already dissected down and I've detached the UCL off of its native attachment site on the base of the proximal phalanx. So here's our ulnar collateral ligament right here. I'll be repairing this back down and adding an internal brace augmentation. So the next step here is to take the guide wire for the nano SwiveLock or the 2.5mm SwiveLock and which I have right here. And as you can see there's a black laser line here at the near the near the end of it. And that's how far you need to drill the the wire. So now I'm going to pass the guide wire for the 2.5mm, or nano SwiveLock into the base of the proximal phalanx. As you can see, this is where the UCL was attached. I'd actually like to place my anchor slightly more distally, so that the distal end of the ligament doesn't flip back when with the SutureTape tails. I'll demonstrate that here in a minute. So I have my guide wire passed just distally here into the phalanx. Now to the laser line. And that's it. So now I'm going to take the drill bit for the the nano 2.5 or nano SwiveLock anchor. And I'm going to use a 2.0mm drill bit. If there's a particularly hard bone, you can use a 2.2mm drill bit. Okay. The nice thing about this drill bit also is that there's actually a positive stop here. That so that, you know, you know, you're not going to be drilling too deep. Okay. So next I want to show you the Point three millimeter SutureTape, which is the appropriate SutureTape to use for the nano SwiveLock anchor. Just a note of caution don't use the smaller 0.9mm SutureTape due to the metal anchor body of the nano SwiveLock the. We found that the 0.9 SutureTape may cut through, so it's better to use the 1.3mm SutureTape, which is what I have here in my hands. And you can also take the 3 or 4 or FiberWire for your repair. Now I've got my Nano SwiveLock anchor fork tip loaded with the 1.3mm SutureTape and a three FiberWire suture. I'm going to go ahead and go ahead and insert this. And as you can see, the anchor body is now sitting on the cortex of the proximal phalanx. And you want to make sure that you clear all the soft tissue out of the way before you insert this anchor body, or else they might get in the way of your of the insertion. So I'm gonna go ahead and grab the tab right here and turn it and apply some pressure. Inserting the body into the bone. And when you start feeling some resistance right there, you know you're down. I'm going to unwind my SutureTape and my sutures from the tab of the driver, and then go ahead and detach this there. And sometimes you'll see this also that the anchor body may not be sitting all the way down. You can just go ahead and unwind this, reinsert it and put it down even more. Good. As you can see there, it's much nicer. So it's nice and flush with the cortex. It's not prominent. You want to pull on your SutureTape and your in your sutures to make sure that they're well seated and they're not going anywhere. So what I'm going to do next is the traditional repair of the ligament. I'll just get my SutureTape tails here out of the way. I'm going to grab a needle holder plant, pass this through the ulnar collateral ligament. You can do any kind of grasping suture that you want. I'm just going to show a very traditional horizontal mattress suture through the ligament. Good. Right there. So another thing that I've been doing recently is that when I see chronic cases, for example, where the ulnar collateral ligament tissue quality is very poor, I'll still do a repair and add an internal brace so you can still do the same thing. You can pass your FiberWire suture as if you're doing a primary repair to bring that ligament or whatever remaining ligament you have back to the proximal phalanx. Do your repair and then add the InternalBrace augmentation, which is especially good for your chronic UCL. I'm just going to go ahead and tie this now. As you can see, I've performed a horizontal mattress repair of the ulnar collateral ligament. And the knot is right over here. I'm going to go ahead and drill the drill the guide wire for the 3.5mm SwiveLock, just proximal and dorsal to the metacarpal attachment of the UCL, which is right over here. So I don't want to violate those fibers. So I'm going to go right here right about just dorsal and proximal to the ligament. And then aim into the metacarpal head down to the laser line okay. So now I have the silver drill bit. This is the 3.0mm drill bit. Remember I'm not using graphs so I don't need the gold drill bit. Make sure your your drill guide is all the way down to the bone. And again drill down to the depth. Stop. Perfect. And sometimes the wire comes out which is fine. You don't want the wire in there anyway for the next step. And then one key point right here is to make sure that your assistant is holding the MCP joint flexed about 30 degrees, which is about right there. Yep. Then why do we do that? Because the proper UCL is most taut at 30 degrees. And if you don't do that, you'll likely lose some flexion at that MCP joint. So with the assistant holding the thumb, MCP joint flexes about 30 degrees and the MCP joint neutral in the coronal plane. You want to go ahead and load up your SutureTape tails onto your 3.5 SwiveLock fork tip. Insert the fork tip into the hole. Let go of the tension on the on the SutureTape tails, and then again do the same thing. Just kind of push in and until your anchor body hits the cortex of the metacarpal. And I'm going to go ahead and secure the SutureTape tails holding the tab. And again applying some pressure so that the anchor body sits nicely again down to the laser line. And once you feel that resistance, you stop. You can pull back on the driver to disengage from the anchor body. And then you just pull off and there you go. So you can see that the 3.5 SwiveLock anchor is very nicely seated in the bone of the metacarpal. You can see your internal brace passing right over the ligament. Go ahead and remove your retractors and test it out. Make sure it's nice and strong against radial stress, which it is. Make sure you still maintain very good motion at the MCP joint and it has a firm stop right there. Okay, so that's pretty much it. You want to go ahead and just cut the remaining SutureTape tails here okay. And then you want to do your standard closure and then immobilize them for about a week. Sometimes I'll get my professional athletes moving even sooner, which is safe to do. But but within a week you can get them moving and then hopefully return to play or work within about 5 to 6 weeks. Just one final note to this is surgery is not just for your professional athletes. This is for really anybody that doesn't want to wear a cast after their surgery for a prolonged period of time. And a lot of patients really appreciate being able to get back to using their hand normally sooner rather than later.

Sanj Kakar, MD (Rochester, MN), demonstrates the 360° scapholunate reconstruction with a volar and dorsal reconstruction option using biologic graft and synthetic SutureTape to augment the repair.
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.

360° Scapholunate Reconstruction With the InternalBrace™ Ligament Augmentation Procedure

So what we've done here, we've done the extended carpal tunnel release. And a critical part of this case is that we have intermittent traction on the median nerve. So the median nerve and the cutaneous branch of the median nerve have gone. And you'll see here the volar capsule. In addition, just at the distal end of the distal radius you'll see the pronator quadratus. And I've released this approximately. And so now what you can see is you can see distal radius. And there's the pronator quadratus with my pickups. And this is important because when we're going to put the SwiveLock using the internal breaks in the graph for the long radial lunate ligament, it's going to come right here. Now I'm putting the thicker wire from the Microsoft anchor in the distal pole of the scaphoid. And this acts for two reasons. Number one it acts as a joystick. And number two, it allows me to put the graft the dorsal limb distally to prevent scaphoid flexion. The next part is the creation of the lunate drill hole. And this is critical. And we want to do is be in the middle of the lunate if possible. But we don't want to go through and through. So in out in if we're too we're to distill, we're going to go in dorsally. Out in the middle and in volley. And then I place the K-wires essentially perpendicular to the dorsal aspect of the lunate parallel to the articular surface. So when the key is being passed, I basically pass this just through the lunate. Once the K-wires is halfway through the lunate, we then check its position on fluoroscopy, and if we like it, we'll accept it. If not, now's the time to change it. So here we're checking the position of the K-wires in the actual lunate. And what we want to do is try and ensure that it's in the middle. And you can see there it actually looks pretty good. So here on the lateral view we're looking at the position of the lunate K-wires. And you can see it's not gone through all the way of the lunate. And that the K-wires is in the middle of the lunate and it's parallel to the articular surface. So the next K-wires is going to be passed to make the scaphoid drillhole. And what I've done is I've taken the distal joystick, I've reduced the scaphoid. And I've gone dorsal distal to volar proximal. And we'll check that on fluoro as well. So what we've now done is gone back. Parmelee. We've put the retractor in and we advanced the K-wires. You can see. Here's the lunate and the scaphoid. K-wires you can see that they're converging in this manner. And so once we've done this, now what we'll then do is go back dorsally and advance the drill over the actual respective K-wires. But this is critical to make sure that the nerve and the flexor tendons are retracted out of harm's way. And we're then going to drill the three millimeter drill through the lunate out the palm side. We've come through the palmar side. Now, what I usually do is sometimes when the drill goes out, the tissues will actually collapse down. So I'll take a marking pen to mark that hole so I know where it is on the palmar side. Now I've made that hole. So I'll take a knife here 15 blade and just open up the capsule. So in this way it allows the graph to pass through this. We've come out. There's the scaphoid. So everything is retracted out of harm's way. We had full control of the K-wires. And there you can see the entry into the capsule. So we've gone in and out, and now we'll take that out and I'll mark in the capsule where the graft is going to come through right there. And again, I will take the knife and I will just open up that capsular hole to allow easy passage of the graft. So what we've done now is taken the straight SutureLasso and push this through the lunate drill hole. You can see it's come out through where the drill passage came out of the capsule. And then through this we'll pass the nitinol loop. And then what we'll do is grab this, and we'll use this now to shuttle the graft going from dorsal to volar through the lunate. So now what you'll see is here's the cannulated hole in the lunate. And we'll use that nitinol loop. And we're just going to take the thinnest end of the graft and pull this in. And this is critical as it goes into the hole. You're watching it and you feed it in. And once we fed it in here, we'll pull it out on the palmar side, as you can see right there. The next part is to take that SutureLasso and again put this through. Now the scaphoid drill hole, push it through and then we'll rotate the wrist and find it on the palmar side. So now here we are on the palmar side. So we'll feed the nitinol loop through. And we'll use this now to shuttle the graft from volar to dorsal. So again we're just going to take a few millimeters of the 400 and FiberLoop that goes through the nitinol passing wire. And we watch this go through the capsule, feed us through the hole. And then we're just going to pull this and it's going to come out the scaphoid just like that. So as we pull you can see now it's an extracapsular reconstruction. But there's the volar SL to complete the 360 degree reconstruction. We're going to go back through the lunate. Now I showed the suture lasso. Alternatively you can use this wire that has a nitinol loop on it. So you can pass this from dorsal to volar. And you can see what we're doing is we're hugging the ulnar side of the lunate drillholes. So not to impinge the graft, we've passed that wire through. And then through this we're going to going to pass the graft. We've put a couple of centimeters through and we're going to slowly pull this in. And as we pull this in, we're going to take a pickup and feed the graft into the lunate drill hole like so and pull this through. So as you can see we're pulling this through. And we're going to turn our attention to this limb of the graft will now be used to reconstruct the long radial lunate ligament at the end. But now you can see we've reconstructed the volar scapholunate ligament. And if we look dorsally, you can see we've reconstructed the dorsal SL right there. And then we have this length of graft. This is why we need about 15cm of graft to tack this to the distal aspect of the scaphoid. Before we put the distractor compressor device in. We're going to put this key. Now in the middle of the triquetrum. We'll use the distractor compressor device that we talked about earlier. And in this way we can reduce the scapholunate interval. We slide this device down and you can see how it fits. And you want to get this as volar as you can. Because what you don't want to do is pull on the graph for your reduction. This is going to get your reduction. And now what's nice about this is once we're down, we can simply push the clamp volume. And I compress, compress, compress. And then once I'm happy I can then lock it in place. You can see just by doing that how it's taken the creep out of the graph. You see, the graph now is loose, but now the joint is reduced. And now we can pull on the graph and put our Bio-Tenodesis screws in our InternalBrace. What we're going to do now is put the first anchor in the scaphoid. And what we'll do is take the three by eight Bio-Tenodesis screw, take it off the driver. Sometimes you can take some xeroform and wipe the driver on so the screw doesn't bind to this, and then pop it back onto the driver. We have the clamp in place. I'm pulling the graph slowly and dorsally, and now we're putting the screw on the radial aspect of the graft in the scaphoid. And we're going to stop once the screw is flush with the scaphoid. Now that's important not to bury the screw, because you'll see that there's a cannulation in the screw which will allow this nitinol passing wire to seamlessly fit through there. If you bury the screw, you won't see this cancellation. So now we're going to advance the 2.5 by six millimeter Bio-Tenodesis screw. I chose this size because the actual hole is pretty full of graft, and I think the three by eight might be too tight. An optional step here is that we reduce the graph with these Bio-Tenodesis screws. Sometimes what I will do is add an extra stitch here. And so what I'll do is take a 200 fiber wire and just come through the graft, just to give it a little bit more rigidity. We're going to thread the internal brace through the cancellations of these Bio-Tenodesis screws. So now what we're going to do is take the wire with the nitinol loop. And we're going to pass this through the cannulation, through the scaphoid and the lunate. And once we do that we're then going to shuttle the 1.3mm SutureTape going through the cancellation of the scaphoid and the lunate Bio-Tenodesis screws. After doing that on the palmar side, we're going to tie the SutureTape. And then after doing that, I'm then going to take this limb of graft, and I'm going to take one limb of the SutureTape and reconstruct the long radial lunate ligament, where I'll place the K-wires to the distal radial aspect of the distal radius. And this is where I'll use the 3.5mm dx SwiveLock. And then place the long radial lunate ligament reconstruction with the internal brace with the wrist in neutral position. At this stage, we can take off our reduction clamp. I then place a micro foot anchor in the distal aspect of the scaphoid, and tie down the dorsal limb of the graft down to it, thereby preventing scaphoid flexion. The critical part of the case at the end of this is capsular closure. So I take the capsule and I ensure then that I with the micro ft anchor, I put the sutures through the capsule and tie it down. I'll also you can see on the lunate there's tissue attached here. And this is important to reconstruct the insertion of the dorsal radiocarpal ligament back down to the lunate. And then in the lunate. Once that's reduced, I'll then take a micro foot anchor and place it in the triquetrum. And finally tether this down so the dorsal capsular closure is critical. I'll then reduce the extensor tendons underneath the retinaculum. Take a free needle on the other end of the suture to go through here. So then you can tie that down. Post-operative protocol. Patients are placed into an AP splint for two weeks, and they can transition then into a short arm cast for an additional 2 to 4 weeks. If you're happy with your fixation, I'll then start them working on dart throwers motion and strengthening. I have not needed to put a K-wires in terms of a scarf or capitate pin, but if you wanted to, at the end of the case, that is completely optional.

Steven J. Lee, MD (New York, NY), demonstrates a novel dorsal reconstruction used in conjunction with SutureTape to treat dorsal and central scapholunate ligament tears. Using the InternalBrace™ ligament augmentation procedure produces secures the repair during the healing process. Dr. Lee displays the 3.5 mm x 8.5 mm SwiveLock® SL suture anchor that allows for knotless, low-profile and high-strength fixation1 during reconstructions and other soft-tissue repairs.
Reference
1. Arthrex, Inc. Data on file. LA1-00053-EN_B. Naples, FL; 2017.
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.

All-Dorsal Scapholunate Reconstruction With the InternalBrace Ligament Augmentation Procedure

Today we're going to be demonstrating the all dorsal scapholunate reconstruction with tendon graft and InternalBrace. Our incision starts off with a incision basically in line with the third and fourth compartments. It's a relatively longer incision than you might be using, purely because we're going to be harvesting a tendon graft. And some of that incision is going to be so we can just harvest an acceptable length. Tendon graft. But starting from between third and fourth compartment, you can also air a little bit on the radial side in order to help access the distal pole of the scaphoid. So here I've opened the skin up and you can see the retinaculum. I'm going to go ahead and open up the fourth compartment. I typically do do a pin neurectomy. And it's also optional if you'd like to go ahead and perform an eye neurectomy at the same time as well at this point. Once I have the proper exposure, and if I realize that I need to do a reconstruction, we'll go ahead and take a tendon graft. So normally you take these millimeter slip of the crp. It's already in our incision that we've made. So no separate incisions are made. And so it's very easy to access. So here I'm grabbing AA2 millimeter slip of graft. Now a two millimeter graft is what you might think is too thin, is actually the correct size for this. And it's certainly strong enough. So once I have this much of the tendon graft dissected out, I'll go ahead and put two o FiberLoop on the end to help to hold the end of the suture. The FiberLoop starts by putting the loop through the tendon first, and then going ahead and making passes through the tendon. Once we make that pass, we're going to go ahead and open up the loop and drop the clamp through and just make about three passes. That's usually strong enough to hold the tendon graft. Great. So I've made three passes. And if you take the clamp off you'll notice. Then you can pull on this FiberLoop and you can realize how strong that FiberLoop is. And holding the end of the tendon. When you take your tendon graft, there's often you can see a Raffi or a division in the tendon in your tendon. So I'm taking an intra tendinous tendon graft. So for the most part, I'm leaving the majority of the EP ecrb tendon intact. So normally I use a tendon stripper and, but I will go ahead and take as much of the tendon that I can see visually here. And then the rest of it I will take with a tendon stripper. And with that technique, I've been able to make my incisions even smaller. The graft needs to be two millimeters in width and at least ten centimeters in length. For the dorsal interosseous reconstruction, it can be a little bit shorter for the interosseous technique, but for the dorsal reconstruction it needs to be at least ten centimeters in length. So this graph that we've taken is just a hair over two millimeters, which I think is just about perfect. Again, if I make this graph too wide, you will have trouble inserting this into the SwiveLock into the hole. And then the total length of this graft is looks like about 11 almost 12cm. So again I'd like to get a graph that's at least ten centimeters for this particular reconstruction. In this specimen we have a tear in the scapholunate ligament. So it's torn through the dorsal aspect and actually including into a significant portion of the central portion of the interosseous ligament. But the volar component appears to be intact. So this is a perfect case for a dorsal all dorsal reconstruction. You can see how this widening of the two bones can certainly occur and cause pain, but as long as there's there's a intact volar component of the interosseous ligament, I do believe that this reconstruction is perfect for this indication. Next thing we're going to do is get some K-wires. We usually put two K-wires in for a joystick, so the planning of the joystick K-wires obviously has to be away from the areas where you're going to make your, your bone tunnels. So in my mind, I'm going to go ahead and make a drill, a tunnel for my swivel locks, probably here in the proximal pole of the scaphoid. And then here in the area of the lunate, and then the last one in the distal pole of the scaphoid. You'll notice in your kit that there are two different drills in your kit. And the to make it simple, the gold larger drill which is gold is for when you use graphs or gold for graft. And the silver drill is the thinner drill. And it's used when you're using this in either suture or SutureTape mode, meaning that you're not using a graft. Kit also comes with a drill guide that has an automatic depth stop. So my second drill hole is in the lunate. And so again I'm going to feel for the distal aspect, the proximal aspect, and try to line it up with the hole that I just made in this. In this scaphoid I'm going to feel the border of the bone on the radial aspect as well. Just again, to make sure that I'm in an appropriate area that I'm not going to break out the cortexes. So I think right about here would be a good spot. So I can feel. I can feel and see the radial aspect of the scaphoid, the ulnar aspect, and I see where the start joint is. So this drill hole needs to be distal to the equator of the scaphoid to help keep the scaphoid from, from flexing. Okay. So I've checked on the fluoro and I'm happy with the positions of my pins. And so then we can go ahead and drill this with again the gold guide and with the with the drill guide that has a depth stop. So go ahead and just drill these out. So prior to inserting my graft I'm going to go ahead and close and joystick my two, clamp my two joysticks together. And that will hopefully close my space between the scaphoid and the lunate as well as to address the DC deformity. So I've inserted the tendon graft into the about 1 to 2mm from the end of the of the ReadiGraft onto the pitchfork. And I'm going to go ahead and secure the FiberLoop onto the end of the square tab and the SwiveLock just for suture management purposes. I'm going to do that on both sides. And then on top of that, we're going to go ahead and place the SutureTape and do the same thing. Secure that onto the tabs on your SwiveLock my ReadiGraft I'm aiming towards the side of the lunate. The order of placement of this, which is very important, is to put it into the proximal pole of the scaphoid first, then into the lunate, and then into the distal pole of the scaphoid. So go ahead and put in our first anchor. The way these anchors work is that you need to go ahead and let the anchor drop into the hole until the anchor body is up against your hole. And once that's there, then you can hold the square tab and turn the pair tab. And that should allow your anchor body to dunk into the hole. You continue turning until you see the laser line is below the level of the hole. If the anchor body has moved down appropriately, you'll also feel a very subtle and gentle give in your handle and lets you know that the anchor is all the way down. So at this point, just a gentle twirl that twirls the SutureTape and the ReadiGraft together just helps facilitate the graft and the SutureTape to fit into my pitchfork. It's super important for both to fit in into my pitchfork. If I, for whatever reason, happen to skewer my telegraph intra tendentiously, this graft will not slide on my pitchfork. So it's very important for this to have to slide, as you'll see in a minute, for this to sit to set into the hole. So I'm going to go ahead and take the pitchfork and grab it somewhere somewhat near to the hole. And again, I've already kind of lubricated this with some mineral oil. And I'm going to let go of my construct, my tendon graft and my suture on the other side. This will self tension itself. So but this is a very important part. I'm going to put some slow but steady pressure onto the SwiveLock. And if I do it slowly enough, you can see the telegraph will slide in and around the hole. So it's important for you not to start turning the SwiveLock into the hole until you see this, which is the anchor body is up against the hole. If you try to do that before that, the the SwiveLock will not make it down into the holes just to get everybody oriented. Again. This is the proximal pole scaphoid lunate that we've already dunked in. And now we're about to go ahead and dunk in the distal pole scaphoid. You can see the hole really well. Now the telegraph slit around my pitchfork enough that my anchor body again is up against the bone. Once that's true, I can go ahead and hold the square and turn the pear. So at this point, any excess suture or graft, I'll go ahead and cut off. Okay. So then we're going to remove the joysticks and hopefully we'll see. Notice that there's the space between the scaffold and lunate does not spread at this point. I do normally put in a pin between the scaphoid and the capitate. So at this point you can notice that the gapping has been reduced to near normal AnaToemic. And I'm going to go ahead and take fluro shots of this. And you can see that the two bones are staying within, each with each other and they're not distancing. We'll go ahead and do the same thing with the lateral. The first thing you may notice is that lunate is in is in neutral position. And then also same when we move this back into flexion and to extension, you notice that it seems to move in a in a normal kinematic sequence, as we would expect in a normal wrist. So here's our final reconstruction. I just wanted to kind of show people you can take your graph. And just to get an idea of how strong it is, take your pickups and just feel it. You feel it's nice and firm and you can feel it on both sides. And again, I didn't do anything for the tensioning it does self tension itself.

Thumb UCL Repair With InternalBrace™ Ligament Augmentation Procedure

Michael Garcia, MD (Tampa, FL), presents collateral ligament reconstruction with InternalBrace™ ligament augmentation fixation using two 2.5 mm × 6 mm Nano tenodesis screws and SutureTape.
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.

Collateral Ligament Reconstruction With the InternalBrace™ Ligament Augmentation Procedure

Hello, my name is Michael Garcia. I'm a hand and upper extremity surgeon from Florida Orthopedic Institute in Tampa, Florida. And today we're going to demonstrate the use of the 2.5 Bio-Tenodesis screw in collateral ligament reconstruction in the hand, particularly for the proximal interphalangeal joint utilizing internal brace technology. These are the contents of the kit. This is a graph sizer which allows us to appropriately size our graft in between 2.0 and 2.5 millimeters. It is important that the graph not be too large for this technique. This is a graft and suture passing device. These are 2.5 and 2.7mm drill bits, the 2.5mm drill bit being used in soft or osteoporotic bone, the 2.7mm drill bit being used in hard bone. These are the guidewires for the above mentioned drill bits. And this is the implant itself, which is a 2.5mm peak tenodesis screw, which is 2.5mm in width and six millimeters in Kilometers in length. We begin the procedure with exposure of the proximal interphalangeal joint. This is a lateral approach of the proximal interphalangeal joint in between the neurovascular bundle bundle and the extensor mechanism dorsally. We have removed the collateral ligament in this case so as to demonstrate a reconstruction. I have already harvested a graft from the palmaris longus. This is a slip of the pulmonary longus and not the entire palmaris longus. We will now use a graft sizer to assure that the graft is the appropriate size, but it will fit through the 2.5mm side easily. After whip stitching the ends of the graft. We are now prepared to perform the reconstruction. The first step is to place two K-wires parallel to the joint and the near isometric points of the proximal interphalangeal joint. I begin with the proximal phalanx. This is a bicortical K-wires. The next key wire is placed in the middle phalanx in and near the insertion of the collateral ligament. Again, this is a bicortical K-wires. Once confirming the position of the K-wires under fluoroscopy, the K-wires are then advanced to tend the skin on the ulnar side of the digit. Once this is done, separate counter incisions are made on the ulnar side of the digit for graft passing. Once this portion of the case is completed, attention can be then turned to drilling the bicortical holes, which will transmit the graft and the tenodesis screw. Once the holes are drilled, we can begin the reconstruction. The proximal phalanx is approached first. The suture passer is passed into the bicortical drill hole and it is passed out to counter incision on the opposite side of the digit, using the whip stitch portion of the graft, and incorporating a SutureTape for an internal brace to assist with immediate stability of the joint. The suture and graft are passed across the digit. This is an advanced until the graft inserts into the hole and is brought out the contralateral side. It is important to take an appropriate length graft so that you can do this for appropriate tensioning. Once this is done, have an assistant hold the suture at the other side of the digit by pulling the suture to one side of the hole. You can insert the screw into the hole and turn clockwise to advance the screw. It is important to maintain tension on the graft during this time period, so that you ensure appropriate fixation of the graft within the hole. This screw should be advanced until it is at the cortical margin. Once this is completed, the proximal segment of our graft VersaGraft has been secured. We can complete the reconstruction using the same suture passing device is introduced across the Bicortical hole and again out the second counter incision that we made. The sutures, including the internal brace and the whipstitch sutures, are placed into this nitinol loop, again pulling across the digit and pulling out the contralateral side. The graft is then passed into the drill hole, and then the internal brace is tightened as well. So now we can see our reconstruction in place prior to tenodesis, and we can assess this geometry of the graft by holding tension on the graft and taking the digit to a range of motion. You can see that this is fairly isometric to a full range of motion in the proximal interphalangeal joint. Once this is done, the joint can be reduced. A mild radial directed force can be applied. Have your assistant hold the the internal brace and the graft, and then the screw is introduced again into its hole. Again advancing to the cortical margin. Securing the distal graft. Once this is completed, the residual graft and suture from the ContourLock side of the digit can be amputated at the skin edge. Now you can see the graft and InternalBrace reconstruction through a full range of motion in an isometric position. The patient is placed into a postoperative dressing and splint to immobilize the digit in extension for a period of 3 to 4 days. The patient is then placed in a removable finger gutter splint in therapy, and allowed for gentle range of motion beginning on postoperative day 4 to 5. There is no forceful pinching or gripping allowed against the graft for a period of 6 to 8 weeks, and only active active assisted range of motion is allowed for the first month.

Arthrex® presents the eleventh episode of the BreakThrough™ program featuring InternalBrace™ ligament augmentation for hand and wrist surgery. The BreakThrough program is an open discussion with leading surgeons that explores how the addition of an InternalBrace ligament augmentation is changing the way that surgeons are treating their patients.
Joining host Christopher Adams, MD, are in‐studio guests, Steven J. Lee, MD, (New York, NY), Steven S. Shin, MD, (Los Angeles, CA) and Michael Garcia, MD, (Tampa, FL) who will highlight their surgeon experience, tips and pearls, and outcomes.

Knotless Suture Anchors

PushLock^® Anchors

SwiveLock^® Anchors

Knotless Suture Anchors

PushLock® Anchors

SwiveLock® Anchors

PushLock^® Anchors

SwiveLock^® Anchors