The Arthrex Pec Buttons are used for fixation of soft tissue-to-bone intended as fixation posts, a distribution bridge, or for distributing suture tension over areas of ligament or tendon repair. Each end of the buttons has an angled face to promote a toggle effect when the buttons contact the opposite cortex, enabling the Pec Buttons to be ideally suited for the repair of ruptures of the pectoralis major tendon back to bone. A unicortical pilot hole is formed with a drill bit and after attaching FiberWire® or FiberTape®&nbsp;sutures from the whipstitched pec tendon, the button is inserted in a unicortical fashion using the inserter.

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Shoulder and Elbow - Next Generation in Repair and Reconstruction 2024

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John J. Fernandez, MD (Chicago, IL), discusses single- versus dual-incision distal biceps repair. He also demonstrates his single-incision repair using a large pec button and the Tension-Slide Technique to repair the distal biceps tendon.

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Distal Biceps Repair Current Concepts and Surgical Strategies

Biceps rupture. We're not going to get into too much of the incidence or the anatomy. I really want to kind of get into the pearls, the pitfalls, what I've learned over the last 25 years of doing the biceps tendons. We'll get into a little bit of the controversies that have to do with it. Randy covered a little bit of the anatomy. Something that's kind of up and coming is the whole concept of the of the distal tendon having two heads, which it does in some people. And that's a, that's something that you have to take into account if you're doing something that's a little semi chronic, because you can go in there and you can see something that looks like pseudo tendon and respect it. And in actuality it could be the long head or the short head component. So you have to be a little bit careful with that. There's a lot that's been done with anatomy pathophysiology describing the watershed area. That's why they tend to rupture. Their 85% of the tendon takes up the space between the radius and the ulna. And this is part of the challenge of single incision versus dual incision. And stuffing too much tendon with suture into that space which can block pronation, which we're starting to see in some studies so far, not achieving a lot of significance. There is a significant decrease in the space from pronation supination, which you can see on CT scan studies. Hutchinson did an awesome job describing the footprint of the tendon, which is ribbon shaped. I mean, you've seen this tendon. It's extremely small or very thin, I should say. And when we're done tubular izing it and implanting it into the bone, it doesn't look like this anymore. And so there's questions as to whether or not that's pertinent. Pertinent rotation of center of insertion when we're inserting these anterior is something that Chris Schmidt makes a big point of. And debriding the radial tuberosity, which Hutchinson made a big point of as being some, some of the anatomy that we have to correct when we're doing the repair. Chris Schmidt, who was one of my Co fellows at the hand center, actually, later when he went into when he went on to UPMC, did a really nice job, a lot of elegant work looking at distal biceps tendons and the single incision and kind of became my nemesis in a way And showed Biomechanically in the lab. Why? Why? Doing it through a single incision or through the anterior approach only can be difficult or impossible to get anatomic. The question is whether or not it's truly clinically relevant or significant. Schmidt showed or compared the anterior versus the true anatomic versus the posterior, and showed that particularly at the end of supination, it can make a difference. History came full circle. The first described technique of a distal biceps repair was a single incision, and it was a direct repair. The problem was that there was a significant price to pay a high complication rate. At that time. There wasn't the technology that we have now. And so one of the first meta analyzes that was done in the 1940s by Derby basically said, probably shouldn't be doing this unless you have a high level of expertise. And part of the reason was the highest level technology that they had was like a goat tendon that you could wrap around the, the radius. And so you would have to expose the radius in a significant fashion, which obviously exposed to significant risk. So the new repair technique came out. Boyd Anderson in the 60s. Then kind of there was a resurgence then given to repairing distal biceps tendons because until then we weren't really repairing all of them or we'd repair them to the brachialis. But it didn't last long. We started seeing complications with heterotopic ossification. And so Failla then came up with a modification, splitting the muscle to try to decrease that risk. Unfortunately, the risk has not gone away. It's significantly diminished, but it has not gone away. And so in the two incision series that you'll see, you will still see a modest incidence because it's one of my most feared complications, 1 or 2% of of a radioulnar synostosis, not just heterotopic ossification. So the single anterior approach again initially started up with the two anchors and then quickly moved on to using cortical buttons once it was described in the late 90s. And then all these publications started coming out in the early 2000, which really then brought on this surge of devices Anterior devices. Posterior devices. Taking the tuberosity down, leaving the tuberosity in place. Modifying it with an interference screw, and obviously the cortical button. This is now my drug of choice. I use a cortical button. This is actually the pec button. I like the PEC button better in terms of how it deploys. There's the BicepsButton which is a little bit smaller and it has a different deployment kit. And the meta analyzes that have come out that have really looked carefully at single incision versus dual incision, have not really shown a significant difference in in what I would call significant complications. When you really look at the results, they're relatively equivalent. You can quibble about pull out strengths and things like that, but it doesn't necessarily translate into clinical differences, complications. This is where I learn all my lessons, and the two that I fear the most is posterior interosseous nerve, of which I've never had one. I've done over 700 distal biceps tendon repairs. I've never had one. I've had plenty of lateral cutaneous neuritis, neuromas, neurapraxia and Synostosis. I've also never had a motion limiting synostosis. I've had a little bit of heterotopic heterotopic ossification. In our study, we had an incidence of about 35 to 40%, but not a not motion limiting the complication rate. When you compare single incision to dual incision in the studies is really relatively equivalent. Again, it's the major complications that I'm worried about. And that's where you do see a different single incision to dual incision. So how do we do the repair? I spend a lot of time at the beginning. So the first thing I do is I'll get my fluoroscopy in, even though I can do the entire procedure without a scan, because I want to get a sense of where that tuberosity is for my approach. As I get older, my incision gets longer and bigger, and that's going to prevent you from number one struggling with the vessels, but more importantly, screwing up the lateral cutaneous nerve and also the posterior interosseous nerve. The you need a longer incision to relax the nerve. No matter how well you release it, if the skin incision doesn't allow you allow you to retract it, you're going to get a Neurapraxia vessels are number two most important on the list. You have to have a way to take these down methodically and carefully. I use a clip, a plier or a clip clip and I basically take those down relatively slowly. This is where I spend three fourths of my case. Is the initial incision the nerve and the vessels. It's easy after that. So this is where everybody struggles and they try to go through that quickly. And then you've got bleeding. You can't see what you're doing, you don't have adequate exposure and then you're dreading the complications later. And so here you can see the tuberosity has been exposed. There's a close up. There's the radial recurrent vessels that I've taken down with the clips. Or you can tie them off. You can see the lateral cutaneous nerve to the left. And here I am now detaching the tendon. And again be very careful that what you're looking at is pseudo tendon. As you know, the pseudo tendon can look almost exactly like the tendon. And in some cases the distal biceps can have very two distinct heads which you would want to salvage to really get a good repair. Here. So here we are debriefing through the actual pseudo tenant. And you can see the split between the long and the short head of the biceps. Now I repair it as a unit. Chris Schmidt advocates for doing a two anchor repair will repair the short and the long head separately. That's a little bit too much trouble for me. So most of us are repairing this as a single unit, which you could argue biomechanically may make a difference, but clinically I haven't seen that be a difference. Here we are resecting it. If you don't know how long it should be. There's two really well done clinical studies that have shown that six centimeters is the magic number. And you'll see this. I also took the liberty of putting in a chronic case very quickly. I use a loop technique. I use a suture loop or I'm sorry, a SutureTape loop. You can use a FiberLoop. That's what I started out with. And or you can use a running locking suture. So it's whatever drug of choice you like. Some of us are even using SutureTape and reinforcing the SutureTape with a fiber wire as well an actual suture locking into it. So once you've got control of it. Of the tendon. I then read the radial tuberosity again. Hutchinson showed that we got to get rid of those osteophytes and those those bone spurs. We then get the guide pin posterior interosseous nerve should be safely at least a centimeter away. You put it, you put the arm in full supination. You don't want to go beyond the perpendicular of the forearm in that position, because that's when you'll get into trouble with the posterior interosseous nerve, especially if you're going to penetrate the posterior cortex. Not such a big issue if you're going to do an intramedullary technique. So here's the guide pin getting drilled across the tuberosity. You can. Then I would highly recommend and suggest that you take a fluoroscopic image. I can't tell you how many times I was sure I was in the right spot. And I take a fluoro image and I'm a good half centimeter or centimeter off. I then use a reamer. I ream it up to about 8 to 9mm. By the way, I use TransFix acid before the tourniquet goes up, and then I'll use a soaked sponge at the end to kind of kind of sop up some of the venous bleeding that will occur in some of the bone bleeding. This is a semitendinosus allograft. This is actually a case that I recently did. And basically weaving that into the end. And again, two really well done studies that showed that the extra tendinous length should be about six centimeters. So you don't necessarily have to guess like you're doing a tendon transfer. And in what position do you put them in. You just cut it at six centimeters. Or if you're going to dock it at seven centimeters and bury it and forget it, there's the distal length. I'm measuring it to six centimeters. And then I'm going a centimeter beyond to basically tuck it into the bone. I do make a hole in the radial tuberosity. There's the cortical button. Basically that's the deployment mechanism. Really simple. There's no tension. I'm using a tension slide suture technique. So basically you don't have to tie any knots. You don't have to guess how long the button is from the end of the tendon. I just popped through the posterior side. You can confirm it Fluoroscopic there you can see the suture sliding. So now you can take all the time in time in the world to get it right. Get the arm in slight flexion again using fluoroscopic imaging, confirming button placement and then basically tying it to itself up into the tendon rehab. Not a big difference. Again, as I get older, my incisions get longer and I get more conservative with my rehab. Not a big difference between early range of motion versus delaying the motion, or holding them back for the majority of the ruptures that you'll see will either be within the first week to three weeks. It's very rare to get a rupture beyond 3 to 4 weeks. You can use a hinge brace. I tend to keep it simple with an ortho splint, basically blocking terminal extension for the first four weeks, allowing active assisted flexion. And the results speak for themselves. But you can get these results using any number of techniques. But again, what differentiates the complications from the good results is the approach. The simplicity of the approach. It's not getting focused on the fixation. Thank you.

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

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

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

Operationstechnikvideos

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

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

Videos de técnicas quirúrgicas

Surgical Technique Videos

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

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

James Guerra, MD (Naples, FL) performs&nbsp;pectoralis major repair on a power lifter using the new Pec Repair Implant Delivery System.&nbsp; He highlights the benefits of combining FiberTape® with titanium Pec Buttons to securely and anatomically reattach the tendon’s small footprint.&nbsp; The new 3.2 mm&nbsp;x 11 mm Pec Button is mounted on a threaded inserter and has large slots that can accept two FiberTapes with needles.&nbsp; The ends of the button are chamfered to facilitate easy unicortical flipping.

Pectoralis Major Repair Using the Pec Button Repair Kit

This is a 30 year old powerlifter who had the typical bench press mechanism where he tore his pectoralis major, and you can see how the pec, when it fires, it moves medially into the chest wall as compared to the contralateral left side. We also see the so-called drop nipple sign, where you can see his left nipple is slightly lower than his right nipple, consistent with the pectoralis major tear. We see how the muscle belly is balled up medially compared to the contralateral side, and we can also feel a palpable defect at the attachment site. When we ask him to fire his pectoralis major, you can see how it balls up immediately into the chest. We're now in the operating room and I've drawn the topographical anatomy. Typically we use an axillary approach. We draw the coracoid process. I also like to locate the deltopectoral interval in case we need to reference this during the operative procedure. I typically make a 4 to 5 centimeter incision in line with the axillary crease. We'll then develop soft tissue planes both medially and laterally to easily mobilize the tissue. So you can see here we're going. We're making our medial soft tissue plane. And then we'll go ahead and make a lateral one as well. I like to place these galbi retractors which frees up my assistant. And now we're looking directly at the clavipectoral fascia. We're now going to split the clavipectoral fascia so we can see the remaining clavicular head. In this particular patient, he has an isolated sternal head tear. The clavicular head of the pectoralis major is intact. And this is many times. This is not an uncommon tear pattern where the sternal head is an isolated tear. So I'm releasing the clavipectoral fascia so we can see the clavicular head nicely. So we can see the remaining clavicular head. Now where teres is at the very bottom of the head. So you want to look carefully at the bottom of the muscle belly and develop the play in this location here. So here I am looking at the very bottom. And I'm going to go ahead and develop this plane at the bottom of the clavicular head of the pectoralis major. And as I pop in here I can see some hematoma. And as I split a little further medially, I'm going to pop into a seroma consistent with the tear. So I'm just developing the plane now. And now I'm going to go ahead and go slightly medially. Now I've popped into the seroma associated with the tear. So we'll develop this plane nicely. And we'll slide a retractor under the clavicular head of the pectoralis major. And you can see now this gives me excellent exposure. So I'm going to reach medially. It doesn't go typically inferiorly. Usually the pec retract. The sternal head retracts directly medially. And now you want to release all of the adhesions on the undersurface of the pec major. And then you're going to release all of the adhesions with blunt dissection with your finger on the superior surface of the pec. Major. And I'm going to clean up some, some hematoma and mobilize the tendon. And many times in these powerlifters, we'll find that the actual tendinous insertion is somewhat macerated like this. The facial tissues actually, you can find it best on the undersurface of the sternal head. So you'll lift up and see that there is actually reasonable tissue on the undersurface of the actual tendon. And you want to pass through and through stitches. Here I'm using FiberTape like the advantage of FiberTape since it has better pull out characteristics, but you could also certainly use number five FiberWire. I place these typically in a Krakow whip stitch technique, typically 3 or 4 sutures. The kick comes with three buttons, and you could also open up additional buttons which are sold individually if you decide to use four sutures. Here I am showing the fascia on the undersurface of the of the tendon. And here I am placing now the last of my Krakow whip stitches, and you can see how nicely we've mobilized the tendon. I like the tails of the suture to exit on the superior surface of the tendon. This allows me to nicely dunk it down against the anterior humerus. So I like to use these 9090 homens to expose the anterior humerus. This nicely retracts the deltoid out of the way as the deltoid. Now I'm showing you the you the anterior humerus. And just medially here is the long head of the biceps tendon. We know that the pec major attaches just lateral to the biceps tendon on the anterior humerus. Now excoriating the anterior humerus to create a healing response. You can do this either with a cob or a little motorized bur. Next we're going to place our uni cortical holes. This is a 3.7mm drill bit that comes in the kit. And you want to make certain you're well centered over the center of the humerus. So you can flip the button in the geometric canal. We place a uni cortical hole so we can easily flip the button. We place our three holes. I like to stagger them slightly to avoid a stress riser. Here I am now, loading the pec button that comes in the kit. An important technical point with respect to loading the button is to understand that we want the button to flip easily within the Intramedullary canal. The button is specifically designed such that its chamfered, and you want the sutures to exit on the long side of the button, which will ease and facilitate flipping within the Intramedullary canal. And I'm going to go ahead and drop that deep into our cortical hole. You want to go ahead and unscrew the locking mechanism from the button, but leave the driver still within the cortical hole. And you want to pull on each of the respective FiberTape in order to flip the button within the auditory canal. These patients are typically young and they have good cancellous bone. So you want to spend a minute here really flipping that button so that it fully seats. So with the tension slide technique, I place all the buttons in the intermediary canal before we actually begin to begin to advance the tendon back to the anterior humerus. So here I am passing the second button. Same technique to remove the stylus, but leave the driver in. As we pull on the sutures to make certain that the button fully flips. And here's the final button going in. And now you want to do that tension slide technique where you pull on each of the respective limbs of the FiberTape to advance the tendon back to the bone. There's a fair amount of internal friction in the system. So once you have reduced before you actually commit and tie things down, you can check it. Make sure you're fully reduced and then tie. So that's the advantage of the of the tension slide technique. There is a fair amount of internal friction. So if you prefer less friction you could either switch to number five FiberWire. Or you could do a single pass through the button technique as well. Once I'm satisfied that the tendon is fully seated, then I'll go ahead and tie each of the respective FiberTape down. And here you can see the final product. You can see the sternal head is nicely reduced to the anterior humerus. My retractor is holding the clavicular. Head down. And now the clavicular head. As you can see, as I release that back down, we have a nice approximation of the sternal head back to the anterior humerus on a beautiful repair with respect to my post-operative care. I typically treat these patients with six weeks in a sling. I'll let them do some gentle codman's so they don't get too stiff. At six weeks. I'll start some physical therapy beginning with isometrics. At eight weeks, I'll allow them to begin some isotonic exercises, and at three months I'll return them to the gym. And I recommend that they build up over the course of six, 6 to 8 weeks in the gym before they get back to their pre-injury status.

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

Unicortical Proximal Subpec Tenodesis

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

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

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

Pectoralis Major Repair using the Pec Button Cadaveric Demonstration

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

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

Speer mit Zahnkranz für 3.7 mm SutureTak und 3.5 mm PushLock

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

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

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

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

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

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

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

2 FILAMENTOS – 1 AZUL E 1 BRANCO/PRETO TIGERWIRE

Sutura de polimistura entrançada FiberWi

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

FiberTape mit Nadeln 17 Inch =43cm Tapelänge

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

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

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

Pec Button Technique

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Surgical Technique Videos (5)

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

Pectoralis Major Repair Using the Pec Button Repair Kit

Unicortical Proximal Subpec Tenodesis

Unicortical Proximal Subpec Tenodesis

Pectoralis Major Repair using the Pec Button Cadaveric Demonstration

Brochures (1)

Epaule & Coude

Catalogs (1)

Shoulder and Elbow - Next Generation in Repair and Reconstruction 2024

Presentation Videos (1)

Distal Biceps Repair Current Concepts and Surgical Strategies

Related Products (6)

AR-2266

AR-2267

AR-2268

AR-2269

AR-2262

AR-2263

Required Instrumentation (1)

AR-1906

Required Accessories (3)

AR-7201

AR-7237-17N

AR-2272