Name: FiberTape® Cerclage Upper Extremity Applications
Uploaded: 2020-07-27T00:00:00Z
Channel: Arthrex
Description: Brad Parsons, MD (New York, NY), discusses the benefits of using the FiberTape ® cerclage system for upper extremity applications, including midshaft humerus fractures and periprosthetic fractures.

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

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VID1-001057-en-US | B | FiberTape® Cerclage Upper Extremity Applications

Brad Parsons

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FiberTape® Cerclage Upper Extremity Applications

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

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