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NanoNeedle™ Scope 2.0
Gains National Spotlight Through

Star MLB
Pitcher's Recovery

John Munz, MD (Houston, TX) shares the unique features and benefits of each VA proximal tibia plate, noting how the design, instrumentation, and fixation options are game-changing for treating proximal tibial fractures.

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A Deep Dive Into the Variable Angle (VA) Proximal Tibia Plates

Speaker  Proximal tibia fractures are challenging injuries, whether from high energy trauma or low impact falls. Anatomical joint reduction and restoration of alignment and stability are critical, which is why precision and fixation is key. These fractures demand versatility. To truly address these complex fracture patterns, we need implants and tools that are as adaptable as the anatomy itself. Let's start with the lateral plate. There are a number of things that make this plate unique. First, the overall contour. It's designed to match the natural curvature of the tibia in both the coronal as well as sagittal planes. When I place this plate on bone, it feels like it belongs there. The oblong holes are especially helpful. They give me the ability to fine tune the plate's position before final fixation. Approximately. The plate has cutouts that facilitate meniscal or capsular repair, and the holes for provisional wire fixation. They're placed exactly where I need them. The slope and contour of the plate, approximately, is subtle but important. It helps minimize prominence over gerdy's tubercle, which is a common issue with other plates. That lower profile makes closure easier and reduces soft tissue irritation. Post-op, we've struggled for years with plates that don't fit well proximally. This one solves that. It's anatomical, low profile, and it's user friendly. That's the kind of design that changes your workflow. Speaker  Now the high lateral plate takes things a further step. One of the biggest challenges with current implants is getting proximal enough to support the articular reduction. Often we've had to place a separate rim plate just to get that proximal for fixation. This plate eliminates that need. The proximal row of 2.7mm screws is perfectly positioned to hug the subchondral bone. That means I can incorporate rafting screws directly into my dominant plate. That's a huge advantage. It simplifies the construct, reduces surgical time, and improves fracture fixation. The direct medial plate is another thoughtful design with 6 to 14 hole options for high energy bicondylar fractures. I need subchondral support medially as well. This plate allows me to place 2.7mm screws proximally in a very subchondral location. The curvature of the plate also facilitates easy passage distally to match the tibial morphology. The direct medial plate also includes recessed areas and holes for suture placement. Whether I'm repairing the MCL or the Pez anserinus, that kind of integration saves me time and gives me more confidence in soft tissue management and the footprint of the plate. It's ideal for schatzker v fractures. It fits right at the apex of the fracture exit, which is exactly where I need support. Finally, the posterior medial plate. Speaker  This one's all about contour ability. The area at the neck of the plate was constructed to be malleable. That allows me to buttress coronal plane fracture exits more effectively. The oblong hole placement is also strategic. This hole allows for fine tuned adjustments in plate location for maximal buttressing fixation, exactly where the fracture requires. Let's talk about screws. It's one of those things that seems simple. Until you're in the O.R. and you need exactly the right length. Screw links increase by two millimeter increments all the way up to 80mm. That's rare. Most systems jump five millimeter increments after 50, which can leave you guessing or compromising. And if you need more screw length, the system goes all the way up to 95mm. So no, we don't do short screws here. As for screw types, the system includes cortical screws, cancellous screws, variable angle locking screws, and crew lock variable angle locking screws. The crew lock screws are especially helpful. They allow for interoperative compression across fracture sites as you insert them. That means I can compress and lock in one step, and because their variable angle, I can direct them exactly where I need. Avoiding joint penetration and optimizing fixation instrumentation is one of those things that can either streamline your case or slow you down. What I appreciate about this system is how intuitive it is. Speaker  Starting with the color coding, 2.7mm instrumentation is red and purple, 3.5mm is yellow and teal. It's simple, it's clean, and it makes life easier for the entire O.R. team, especially your techs who now don't have to play the guessing game with drill guides, drill bits, and screwdrivers. Everything in this system is calibrated off the drill bits that can save time and reduces error. The option for manual length assessment is also provided with easy to use depth gauges. And what about for percutaneous screw insertion? The percutaneous instrumentation is a game changer. It's efficient, it's accurate, and it keeps the procedure minimally invasive, which helps reduce soft tissue disruption. The ability to place a triple sleeved guide that fits into the plate and then drill, measure and fill without hassle is very unique among systems currently available. In patients with robust soft tissues, this can minimize surgical dissection and prevent intraoperative struggle. From plate design to screw versatility to streamlined instrumentation. This system is engineered for the realities of surgery. Every element reflects the expertise of surgeons who have encountered these challenges firsthand. These are not just tools. They're purpose built solutions designed with precision and insight to support performance in the O.R., where thoughtful design truly matters.

A Deep Dive Into the Variable Angle (VA) Proximal Tibia Plates

The consolidated trays for the Univers Revers™ total shoulder system are designed to provide a cost-saving solution that preserves patient-specific optimization and enhanced operative workflow.

Univers Revers™ Total Shoulder System: Maintaining Global Patient Parameters With Fewer Trays

Speaker  Shoulder arthroplasty is evolving and so are we at Arthrex. We're giving surgeons a streamlined path to surgical excellence. Fewer trays with the same versatility you've come to expect. All to help you treat your patients better. The result? A dramatic reduction in O.R. waste and significant cost savings without compromising implant modularity or patient optimization. Our new consolidated system lets you perform a standard reverse case with just two trays and an augmented glenoid with only three trays, saving you space and streamlining your workflow, all while continuing to use the implants you're familiar with. Backed by over a decade of clinical data. Fewer trays. Same implant options. More efficiency.

Univers Revers™ Total Shoulder System: Maintaining Global Patient Parameters With Fewer Trays

DynaNite® CT nitinol staples deliver active compression for secure sternal closure, applying proven orthopedic fixation principles to cardiothoracic surgery. With two low- profile staple size options, the system offers flexibility to accommodate patient anatomy and surgical technique. Engineered to ensure consistent sternal stability throughout postoperative recovery, DynaNite CT staples work in combination with FiberTape® cerclage to deliver a comprehensive solution for sternotomy repair.

DynaNite® CT for Sternotomy Closure

Low profile Superelastic dynamite CT. Nitinol staples are available in two sizes, designed to accommodate a range of patient anatomies before closure. Measure the thickness of each sternal have to ensure secure fixation without compromising the posterior cortex. Choose a staple that is at least two millimetres less than the thickness of the sternum. With fibertape sternal closure completed, the dynamite drill guide is then positioned centered and perpendicular, setting the stage for precise implantation. The dynamite CT system features a specialized positive stop drill bit designed to safely drill into the sternum, preventing overpenetration to protect underlying tissues using the loading device. The dynamite staple legs are adjusted to match the width of the drill guide. The staple leg should be in parallel or near parallel position to facilitate compression of the sternotomy once inserted. Once seated, the device is released, allowing the nitinol to return to its original shape, delivering targeted active compression to the sternal body. A tamp ensures the staple is fully seated. Additional staples can be placed as needed as an adjunct to fibertape sternal closure. A minimum of two staples is recommended to optimize fixation and enhance resistance to lateral distraction of a median sternotomy. Dynamite CT, nitinol staples and the Fibertape sternal closure system deliver the strength, compression, and flexibility needed to optimally personalize sternal closure for every patient.

DynaNite® CT for Sternotomy Closure

The QuickPass™ FiberTape® Cerclage System features cannulated, slotted passers that allow simplified passage of FiberTape Cerclage suture around bone for fracture management. The QuickPass tube on the FiberTape Cerclage suture facilitates quick insertion through the cannulated hook, and the suture is removed from the slot to complete a wrap around the bone without the need for a separate shuttle suture.

QuickPass™ FiberTape® Cerclage System

Speaker  The Quick Pass Fibertape Cerclage system features Cannulated slotted parsers that allow simplified passage of Fibertape Cerclage sutures around bone for fracture management. A variety of hook sizes and geometries are available depending on the fracture site and surgical approach. The quick pass tube on the Fibertape Cerclage suture facilitates passage through the cannulated hook, and the suture is removed from the slot. To complete a wrap around the bone with the appropriate passer selected and placed around the bone, insert the red quick pass tube through the proximal cannulation of the hook until it exits the distal part of the cannulation. Remove the fibertape cerclage. Suture through the slot of the passer to allow for a second pass through the cannulation. Repeat the previous steps to complete a second pass of the Fibertape Cerclage, ensuring the Fibertape Cerclage sutures have been removed. Remove the passer from around the bone. Pull on the tail of the fibertape Cerclage suture to remove slack and advance the loading device closer to the bone. Cut the quick pass tube from the Fibertape Cerclage suture. Place approximately 2 to 3in of the tapered fibertape suture tail into the nitinol loop of the loading device. Separate the two tabs of the loading device, pulling the nitinol loop and the fibertape suture tail through the pre-tied knot. Unclicked the remaining suture and remove the knot from the loader. Slide the knot down to the bone and tighten by hand to remove the gross slack from the cerclage loops. Position the not so that it doesn't interfere with the placement of other implants, for example, plates and or strut graphs that may be used. Cut the fibertape cerclage near the swaged part of the suture to separate the two limbs. Insert one cerclage suture limb through the bottom hole at the distal end of the tensioner. Speaker  Slide the tensioner down to the knot of the fibertape with a tensioner secure against the knot. Place the other suture limb into the top slot at the distal end of the tensioner, pulling tight on the suture limb. Wrap one suture limb around the main body of the suture wing on either side of the tensioner, making at least one full pass around the suture wing. Then wrap the suture limb around the cleated portion on the side of the suture wing to lock it in place. Repeat this step with the other suture limb on the opposite side of the tensioner. Turn the handle clockwise while holding the tensioner body to tension. The fibertape cerclage suture tension until slack is removed and the desired amount of compression is achieved. The gauge lines on the tensioner provide a reference and aid in applying a consistent amount of tension. When multiple cerclages are used. Caution should be taken to avoid over tensioning and going beyond the fourth gauge line. Turn the handle counterclockwise and unwrap the suture limbs to remove the tensioner. Tie a half hitch knot to secure the cerclage construct. Place additional fibertape cerclage sutures if necessary. After initial tensioning and applying the first half hitch knot, each cerclage can be re tensioned if necessary until the desired amount of compression is achieved. Tie two alternating half hitch knots to complete each cerclage construct and cut the remaining suture limbs. The low profile nature of Fibertape cerclage allows for the flat suture cerclage construct to be placed under or over a plate. The Quickpass Fibertape Cerclage system provides a simplified and quick technique for achieving all suture. Cerclage fixation for long bone fracture applications, including proximal humerus and femur fractures.

QuickPass™ FiberTape® Cerclage System

At the Hand and Wrist Fellowship Forum, Joshua Hustedt, MD (Phoenix, AZ), discusses the use and recent literature surrounding CMC denervation procedures as an adjunct option for the management of CMC arthritis.

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Thumb Carpometacarpal (CMC) Arthritis: Literature Review on Thumb CMC Denervation

OrthoPedia: Thumb Carpometacarpal (CMC) Arthritis: Literature Review on Thumb CMC Denervation

Designed to provide anatomic contour with precise instrumentation, the Arthrex Proximal Tibial Plating System features 4 unique plate styles, equipped with advanced variable-angle locking capabilities and KreuLock™ locking compression screws, to optimize treatment of proximal tibial fractures.

Arthrex Variable-Angle Proximal Tibial Plating System

Arthrex Variable-Angle Proximal Tibial Plating System

Aaron J. Krych, MD (Rochester, MN), demonstrates all-onlay medial patellofemoral ligament (MPFL) and medial quadriceps tendon femoral ligament (MQTFL) reconstruction techniques using the MPFL Reconstruction Kit with hybrid Knee FiberTak® anchors.

All-Onlay MPFL Reconstruction

Hi everyone. My name is Aaron Critch from Rochester, Minnesota and we're very excited to show you all Onli Mpfl reconstruction today. We're going to do both online fixation for the patella as well as the femur, using our new knee fiber Tak Mpfl reconstruction kit. Let's take a closer look at everything that comes in the knee fiber Tak Mpfl reconstruction kit. The first is the very innovative ratcheting Knee fiber Tak guide that's going to help us place our anchors on the patella. We have a 2.8mm knee fiber tak hard bone drill. We have three hybrid knee fiber tacks. They come on non self punching inserters. What we'll use for online fixation on both the patella as well as the femur. We have our fiber snare to help us with graft passage through our soft tissue layers of the knee. We have our familiar Fluoroscopic shadows point guide that's going to help us accurately place our femoral point for the mpfl reconstruction. We have a graph prep board and sizer. And finally we have two fiber loops that come on the 0.9mm tape. Here we have a right knee for our Mpfl onlay reconstruction. So we made a medial incision to the patella. We made it just a little bit longer for visualization. Really wanted to show this technique this online technique. So here we've found our retinacular layer between layers two and three. So we're just going to come down one level onto the medial aspect of the patella. And one thing that's very important with our onlay is we really need a good bone prep. So you can see here where extra articular. Here's the top of the patella. We're down to the 50 yard line. But we have a nice bone prep here. And we really want to encourage that surface healing for the onlay technique. So a couple pearls to be able to place these knotless fiber tacks on the mobile patella. So one is we place the knee into some flexion, which gives some more inherent stability of the patella and the groove. And really the game changer here is our knee fiber tack ratcheting guide. So our ratcheting guide can help us completely keep the patella stable. So you don't need to rely on a lot of back pressure or an assistant while you're doing your drilling. So you can see the spiked edge goes here on the lateral side. And then this ratchets down on the medial side. So we'll place that superior anchor first. So I'm just feeling the lateral side of the patella. And then we're going to ratchet down for our superior anchor. And we can really get some great stability. You can see we have nice and total control of that patella. So then we're going to take our 2.8mm hard bone drill. And I'm doing this without an assistant. So this male has really hard bone. So we're going to make sure that we cycle a few times. And then once we have our knotless fiber tech hybrid anchor, this is non-self punching. So we can just get it started and then just give it a few gentle taps to seat it. So you can really see how our guide stabilizes the whole entire system here for us. So once the anchor is seated then we can unravel our sutures. And again this is the hybrid option. So we have our needles here and we have our blue knotless suture that's already pre converted for us and our little white suture to maintain our loop. So now we can take our guide away. And there's a little slot on the side where the sutures can come out easily. And then we just want to make sure we have really good fixation. You can see we've got complete control of that patella. So now we're just going to separate out our sutures. So we have our two black sutures and they come pre-loaded with needles. So we're going to use this to actually help us reconstruct the nwcfl portion. So we'll put those on the side. And then here you can see the pre converted loop that's ready to go. You can check to see if it slides a little bit. But we want to put our graft directly through this loop. So we're going to come in here and place our second anchor. This one's going to be more distal at about our 50 yard line. So here I'm just really ratcheting again have really good one handed control of that patella. And then we'll come in here with our 2.8mm drill bit. It's really hard bone here. We'll just cycle a couple of times. And these are non punching inserter. So we'll just get it started. And then we'll be able to tap the anchor down fully seated. So that's positive. Stop. So then we'll take off our sutures and be ready to go with our second anchor. So now both hybrid anchors are fully ready to go on the patella. You can see we have our two knotless loops here which we'll put our graph directly through. And then we have our two sets of needles here that we're going to show you how we incorporate these into the reconstruction as well. So now we're ready to pass our graft on the patellar side. So this step is quite easy because we don't have to do really a lot of graft prep. On the back table here. All we did is we placed a mark directly in the center of the graph. So we have our graph center point measured. And we're right between our two knotless loops. We are going to perform an MQ TfL portion of this reconstruction. So what we'll do is we'll take the center point. And we're just going to shift it proximally right into that first loop. And that's going to give us a little extra graft to do our MQ TfL portion of the reconstruction. So once this is set up now we can use our Knotless portion. And we're just going to bring these down one at a time. And again we're trying to line this one up with the Blues. So we'll just set provisional tension. And you can see how this really gets amazing fixation of your graft. So we have that tissue compressed right to bleeding bone. And our fixation on the patella is fantastic. You can see we have complete control here. So we have our two anchors secured on the patella. Right here is the superior aspect of patella. And here's the quad tendon. So what we're going to use is a portion of the hybrid anchor. Now to actually perform part of the reconstruction. So we're going to really recreate the quadriceps portion of our stability. So here we're taking the preloaded needle. We're going through our graft. And here you can see our quad tendon. So we're going to actually dock this right on the undersurface of our quad tendon. And it's as simple as that. And now we're just going to tie a knot for fixation. So once we have the graft fixed here you can see we have fixation above the patella into our quadriceps about a centimeter to 15mm. And that's why we need a little excess graft above. But now our fixation is complete on the patellar side. So now we're sewing both limbs of the graft together. And this is our 0.9mm suture tape. So it's very important that we have both limbs of the graft on equal tension here and clamped. What's nice about this technique is we don't have to worry as much about length as when we're creating a socket. Technique. The onlay technique is a little bit more versatile and flexible that way. So once our patellar fixation is complete and the graft is ready, we'll work on our femoral side. And again this is onlay fixation on the femoral side. We don't want to neglect the most important part of the operation which is getting the anatomy correct. So I still like to use shuttles Fluoroscopic guide. And we have a 2.4mm guide pin just like any other variation of the technique. So we want to make sure that this is lined up really well on x ray. X-ray and we also confirm isometrically with our pin. So once we have our pin placed radiographically, then we want to make sure we're okay from an isometric standpoint. So we're going to pass our clamp here extra Articularly. We have our fiber snare shuttle that we're going to use to shuttle the graft between the layers. So now our sutures are loaded in the fiber snare. So I'm just going to lift up this layer. And then we're going to shuttle our sutures. First they're going to come out our femoral incision. And then our graft is going to follow. So you can see our graph length looks good. Now we're going to check our isometry. So here we're in about 90 degrees of flexion. But we really want this graft isometric from 0 to 90. So I'm going to place my finger on the graft and the pin and make sure that this is isometric through a 90 degree range of motion. And typically the mistake is to place the pin and the point a little bit too anterior or proximal. But this one feels very good. So we're happy with both our radiographic landmarks anatomic landmarks and our isometry. So once we've confirmed our 2.4mm pin placement, now it's time to place our anchor. One of the other aspects of this ratcheting guide is that this guide will completely detach. And then we can slide this right over our 2.4mm guide pin. And this helps protect it. Now if you have really hard bone you could remove this pin and go back to your 2.8mm drill. But in most cases we're able to just remove our two four pin and then place our anchor in that same pilot hole, so we'll tap this in to a positive stop. So again we're we're hybrid anchor on the femoral side as well. So we have both our knotless loop for our graft fixation but also an extra pair extra set of needles to help us with additional fixation. So we're going to set that anchor make sure we have great fixation. And now we're ready for graft fixation. So we're ready to go for graft passage on the femoral side and fixation. It's very important to remember we really want to do a good biologic preparation. So typically I'm really taking a curette here and just kind of really scraping that periosteal bone. Again one of the key elements we need with our onlay fixation. So then we can pass our, our graft sutures through the loop. So we'll typically pass our sutures first. And then we'll make sure this graph is lined up. Now the tension of the graph obviously one of the most important aspects of Mpfl reconstruction. So you can notice our knee here is in 30 degrees of flexion. So our patella is starting to engage in the groove. And then we don't want to over tension. So you don't have to put a lot of tension on this graft. But we'll first tension the loop down and. We'll bring that right down. And that that sucks down the graft really nicely. You can see the fixation that you get there on the surface with our Onlay technique and our knotless fiber tack portion. So now we can use the other portion of our hybrid fiber tack. And we're just going to get some fixation of the graft proximally towards your patella side. So here on the anterior portion we'll just place a simple suture. And then in the posterior portion, we can place a mattress suture through the graft. When we looked at the biomechanics of this construct, this was very much equivalent to a socket type of fixation. So again, a lot of advantages for maintaining bone real estate with this onlay technique. And you get one more point of fixation. With the knotted suture limbs. So if you want at this point you can retension your knotless portion. But everything here is very secure. So we'll just trim our sutures. And then this excess graft at this point you can trim as well. And that's one of the nice aspects of the Onlay technique. The graft length does not matter as much once we have our surface fixation. So once our graft is trimmed, you can see the broad footprint of fixation that we have here against our prepared bleeding bone. So a true onlay technique both on the patella as well as on the femur. Okay. So at this point we've got everything secure on the patella as well as the femur. So we're just going to use the remaining sutures to repair our retinaculum. So these two tensioning limbs at this point we can trim. And then we still have our double loaded needles from our hybrid anchor previously. So we're going to use these to help repair this retinaculum. Sometimes there can be a retinacular injury as part of this constellation of instability. But these do a really nice job of just closing Everything up and securing it to your patellar side. So I typically just place two simple sutures, one on each side of the retinaculum. So at this point our sutures are set and we can complete this retinacular repair. We can also perform imbrication if needed. But at this point our graft is set and we'll trim these. And you can see our final repair on the patellar side. Again we have our fixation not only on the patella but also in the quad tendon as well. So overall very nice online procedure.

All-Onlay MPFL Reconstruction

This animation provides an overview of the features and benefits of the Knotless 1.8 FiberTak® soft anchor for the treatment of shoulder instability.

Knotless 1.8 FiberTak® Soft Anchor for Shoulder Instability Repair

Knotless 1.8 FiberTak® Soft Anchor for Shoulder Instability Repair

John Ogunlade, DO (St. Louis, MO), demonstrates the technique for decompressing the lateral recess through an interlaminar endoscopic approach.

Endoscopic Approach to Lateral Recess Decompression

Speaker  Hi, my name is John Ogunlade. I'm an endoscopic spine surgeon. Today I'll be presenting on lateral recess decompression. So first you want to chew AP through the intended surgical level. So we're going to be targeting L405. What you can see here, this is the interlaminar window of L405. And then we're going to mark this inferior medial edge of that lamina of the L4 level. And that looks pretty good. We're right at the midpoint of that inferior medial edge of the lamina. And that's where we'll make our incision. So we'll make an incision through the fascia. And then we'll go straight in following the angle of our c-arm until we find a positive stop. And that's a positive stop there. You can actually see that I'm scraping the bottom edge of that inferior laminar edge there. And that looks great. So that one step dilator is on the inferior edge of that lamina. And then we'll use a tubular retractor to dilate over that one step dilator. And I like to have the bevel facing cranially. So that way when we come in, the first thing that we see is that area we're targeting the bony surface. And then now we can bring in our scope. So now that we've brought in our working tubular retractor, we're going to introduce our radio frequency flex tip probe to identify the area that we just targeted. So for orientation purposes, you can see that the bevel of my cane is facing cranially. Speaker  So this is towards the head. This is towards the feet. We are here. This is lateral and this is medial. So now that we brought in our tubular retractor, we're going to now expose that inferomedial edge of that L4 lamina. And this is kind of exposing what we were targeting so that we can start our lateral recess decompression. You can see this little slope here kind of signifies where that medial edge of the lamina falls off. There's a little bit of fibers from the facet capsule. And we're ready to start our drilling. So we're going to introduce this drill. This is a little bit more aggressive. And really we want to drill along this attachment of this ligamentum flavum where it attaches to the ventral surface of this lamina. So you can see this is part of this defect that I just created using the drill. And you can see this is actually the ventral surface of the lamina where we're going to focus our drilling. And we're going to follow this nice curvilinear path along the inferior edge of the lamina so that we can detach the ligamentum flavum. We've seen how you can use the fluted burr for more aggressive resection of the medial border of the medial facet joint. I'm going to now demonstrate how you can use a diamond burr to really target and remove some of this attachment of the ligamentum flavum. Speaker  But really what I want to demonstrate here is how we're using this diamond burr push directly on this ligamentum flavum and drill right along the attachment of the ligamentum flavum. And that's how we're going to detach our ligament and do our lateral recess decompression. Often we'll run into the most cranial extent of our interlaminar window and we may have to extend that. So what I'm going to do is I'm going to use this diamond burr to polish off some of this soft tissue. Then we're going to also extend our interlaminar window more cranially so we can reach the insertion of the ligamentum flavum. So what you might see here is by just gentle pressure on any soft tissue, you could use that to polish and remove that soft tissue attachment from bony surfaces, so that you don't have to go back to using a pituitary or any other instruments to increase your field of vision. So we're going to deploy our sheath here. And we're going to go more cranial to remove some of this laminar edge. So we can continue our detachment of that ligamentum flavum. And the goal here is to work in planes. So once you have reached the depth that you want for your detachment, the ligamentum flavum, you're going to keep that depth and you're going to follow this curvilinear path all the way caudally so that you get nice smooth lines. Speaker  So before we get to the cranial attachment of our ligamentum flavum for our lateral recess decompression, it's important to find the inferior border of this caudal attachment and expose it. This is a little bit of synovium here. We're just going to move that out of the way. What we'll do is we'll use the drill to detach the Ligamentum flavum both Cranially and Caudally. And I can feel a bone deep to this soft tissue. It would be great to expose this so that when you go for your caudal ligamentum flavum detachment, you can actually see the removal and the detachment of that caudal ligamentum flavum. So again we're on the patient's left side. This is now the top of the L5 lamina right where it becomes the spinous process. And what you can see here this is the inferior articulating process of L4 on the left that's coming to create the joint with the SAP, which is going to be right underneath this soft tissue. And what we want to do is we want to trim this ligamentum flavum off of the ventral attachment of this L5 lamina. So that's going to be part of our goal. And we'll use the shaver to do that. Right now our orientation the top of the screen is directly cranial. Speaker  So this is towards the head. This is towards the feet. This is lateral and this is medial. And what you're noticing is that I'm constantly changing the rotation of the scope by adjusting my hand so that I can get the best view without destroying tissue. That's unnecessary. So this is the medial border of our inferior articulating process of L4. That's our ligamentum flavum attachment to that inferomedial articular process of L4. And now you can see we're now attaching the ligamentum flavum from the ventral surface of the L5 lamina. So you can see here this is the cranial edge of L5 and the ligamentum flavum attaching to the ventral surface of it. We're going to detach that using this diamond burr. And again you know there's different shaver burr tips that you can use whether it's fluted or diamond burr. I would argue that you should use a diamond burr for this step, as the attachment of the ligamentum flavum will come up very quickly. Okay, so what we're looking at now is the facet joint. This. Here to the left is our inferior trickling process of L4. And this here is our superior articulating process of L5 coming up from the lamina of L5. We're going to drill along this attachment of this ligamentum flavum. And for the goal of this surgery for decompressing the lateral recess, we really need to get to the superior articular process as that's our compressive lesion. Speaker  If the patient has significant amount of ligamentum flavum hypertrophy by detaching it from the superior articular process, you're also decompressing the neural elements. So now we can start to detach our ligamentum flavum. You're starting to see the ligamentum flavum thin out to this thin wispy white insertion point. So we know that we've detached it caudally. We can now follow this out laterally, and it's very hard to get the lateral attachment of the ligamentum flavum completely because it goes out the foramen. However, you can use this as a guide of detachment from the actual superior articulating process of L5 in this case. And from there we'll make our turn cranially so that we can detach the flavum off the ventral surface of L4 and go all the way to our cranial attachment. So now we're drilling along the medial ventral surface of L4 along the IAP to the lamina. So occasionally I would encourage you to take a break so that you can actually clean up some of these surfaces and remove some of the soft tissue that may impede your view, as in this case, some of the soft tissue creep was getting in our way. And I want you guys to see the attachment of the ligamentum flavum. So now we're here along the medial border of the facet joint. And we're going to continue to remove this ligamentum flavum from its medial attachment. Speaker  We can follow this all the way up cranially and caudally so that we're making one smooth line across the switch that joint. And now we're getting to the attachment of the ligamentum flavum. So now you can clearly see the attachment of the ligamentum flavum ventrally at the caudal aspect of the L4 lamina. And as we continue to work with our drill, we're going to detach it completely. And then we'll use our Kerrison to remove the ligamentum flavum on this ipsilateral side. So we're detaching the ligamentum flavum from its cranial L4 attachment. So it looks like the ligamentum flavum is ready to be detached. We can continue using the drill. Or we can use this angled curette to now detach the ligamentum flavum. We're going to use this Curette to go circumferentially around the ipsilateral medial facet joint and come all the way down to the lamina of L5. So now that we've detached the ligamentum flavum, both cranially and caudally, we'll use the kerosene to detach ligamentum flavum. You can see this. Here is the sap here. We'll decompress that as well. We're going to grab the ligamentum flavum, and we're going to peel it off from caudal to cranial. So you can see our neural elements and our thecal sac down below. This is our sap here. And now we can actually take down some of this sap. Speaker  Now we're just going to remove the bulk of this ligamentum flavum. It's still attached medially. So it may be hard to get out, but you can typically detach it in one big piece. So we've successfully detached the Ligamentum flavum, both Cranially and Caudally. Now we're just going to remove this ligamentum flavum with the pituitary. So you can see we have our dura exposed. There's still some flavum here. Medially. We can use a kerosene to detach that. But you know I'm going to use the shaver. We're going to go a little bit more lateral with our lateral recess decompression so that we can get to the lateral edge of that exiting route. So. This is now our AP. You can see that we've now completely decompressed this traversing route. It's the last of our ligamentum flavum still attached here as it starts to go out the foramen. Oftentimes you might find that the facet joint is significantly overgrown. And as in this case, you would want to make sure we have a thorough decompression until we reach the edge of that lateral recess and the traversing root. So that would require us to remove a little bit more of this medial facet joint. So if you don't get to this edge of the sap, you may have an insufficient decompression. So don't be afraid to go back, bring in your shaver and safely remove the medial border of overgrown facet joint so that you can reach the lateral edge of this traversing root to ensure that it's decompressed. Speaker  And now we use this soft tissue shaver to clean up some of these floaters. So now that we've done our lateral recess decompression we'll take a look at the anatomy. So right now we're resting on the superior edge of the L5 lamina. You can see our laminectomy defect where we have detached the ligamentum flavum from the ventral surface of the lamina. Here is the superior surface of the L5 lamina that we've detached the ligamentum flavum. You can follow this lamina up to the sap. You can see that this is now the lateral recess. And this is our traversing root completely decompressed with our disc space underneath. We continue in this orientation here. We'll go out the foramen. And again, the goal of our lateral recess decompression is to make sure that this traversing root is completely decompressed from the inferior border of that disc space to the superior border of that disc space. You can see it's completely mobilized, and that's our disc underneath. So if you look at the pre-op image and compare it to the post-op image, you can see that our interlaminar window has been widened and that the lateral recess and the facet joint has been trimmed very minimally to decompress that traversing root.

Endoscopic Approach to Lateral Recess Decompression

Benjamin G. Domb, MD (Chicago, IL), demonstrates a hip capsular closure using the SutureCast™ suture passer and LoopLoc™ knotless implant. Dr. Domb provides surgical pearls for suture management and tensioning of the LoopLoc implant to complete the closure.&nbsp;

Hip Capsular Closure Using the SutureCast™ Suture Passer and LoopLoc™ Knotless Implant 

Speaker  My name is Benjamin Dome. I'm the medical director at the American Hip Institute. And today we will be demonstrating capsular closure in the hip using the suture cast passing device and the loop lock capsular closure device. The suture cast can load and expel up to 40mm of suture under the capsule. In order to load it, we switch the switch forward and then put the suture into the jaws, and we put it all the way into the apex of the jaws beneath the teeth. And then we load the suture like so. And again, if we fully retract the button, then that pulls in up to 40mm of suture. Once we've passed through the capsule, we can similarly eject that 40mm of suture like so. In order to pass the suture through the other side of the capsule, we pass the suture cast through the other side of the capsule, extend the jaws, and then use the teeth on the jaws to grasp the suture. So we want to grasp the suture very close to the apex of the jaws, and then retract like so, and pull it through the other side of the capsule. So here we're going to load the end of the fibre link from the loop lock into the suture cast. So we place it like so into the apex of the jaws, and then retract this all the way again. It can retract up to 40mm. We will then come in through the mid anterior portal. Speaker  We're going to grab the capsule just beneath the rectus femoris. So this is the indirect head of the rectus femoris here. And this here is capsule. We grab capsule just beneath the rectus femoris. And this is on the acetabular side. So we penetrate through the capsule here. And then we can inject our suture like so. And then we'll come out with the suture cast. I'm going to come in through the distal anterolateral accessory portal, which gives me a good angle to grab the capsule on the femoral side. We'll come in through the capsule on the femoral side here. And we'll use the jaws to grasp this suture. Like so. And then we pull the suture all the way through. At this point I'm going to bring both sutures into the same cannula. That. My assistant will hold on to the loop lock like so pinching the white tab against the black card. And we're going to pull through the capsule. Hold the scope please, Until we see the end of the loop block here. And at this point we'll cut. So I'll cut the fiber link. So now we take the suture off of the tab one. And we're going to pull out the suture from tab two. And we want this suture to come all the way out of the card out of tab two. And then we pass the end of this suture through the loop. Of the loop block. Speaker  And then we pass it through the wire loop attached to the white tab. And at this point we pull through using the white tab. And now we are about done with the card. And we have these two ends which we need to even up. So we're going to pull tension on that suture until our ends become even. So now with our ends close to even, we put our finger in the middle here and pull on the middle so that we have even everything up. So a pearl to minimize the friction as the loop lock is tightened, is to place a retriever into the joint and to grab the loop on both sides. So we grab the loop here and we grab the loop here. And in this way we are actually setting up a construct where the Friction will be against the retriever rather than the sutures having friction against one another. So we can lock the retriever there and then proceed with tensioning. Tensioning can be performed one suture at a time, or it can be performed with both sutures at the same time. And I'll demonstrate the latter. So let's just hold like that, please. The retriever, our assistant will hold the retriever. And I'm going to tension both sutures at the same time here bringing the mechanism down into the joint. And then when we are near, we will release the suture retriever and take it out and complete the tensioning of our loop lock. Speaker  And that completes the capsular closure in this location. We can now use a closed ended cutter to cut the remaining suture. And the closed ended cutter will pass down right on to the loop block device. So here's another view showing that capsular closure right beneath the indirect head of the rectus femoris, which has been preserved in its entirety. We'll now move on and do a second loop block for demonstration purposes. And it's interesting to note that one option is to put the first loop block in and not tension it entirely. Then pass the second loop block and then tension both sequentially. In this case, for demonstration purposes, we've tightened the first one entirely and we'll now place the second. As I open the suture cast device, note that the jaws actually open side to side in a horizontal fashion rather than vertically. Again, we'll pass the end of the suture from the fiberlink into the jaws. There. The horizontal opening makes it easier to catch the suture without catching capsule. So here we're going to come again through the acetabular side of the capsule and take our bite. And coming inside the joint. We can view as we expel the suture. And then we will come through the femoral side of the capsule. Here. Take our bite. Extend our jaws. And grab our suture and then pull it through. Hold the scope, please. As before, we pass this fiberlink all the way through. Speaker  The capsule until we see the loop lock. We'll cut the fiber link here and now. We will take off tab number two. Take the end of the suture. Pass it through the loop lock, then pass it through that nitinol wire attached to the white tab and then pull the white tab through. That. At this point, we detach from the card. And we even up our ends. So when the ends are all the way, even then we can put a finger in the middle of the loop and make sure we have pulled all the slack out of the loop. And at this point, I'm going to tension this by tensioning both at the same time. And we'll see that that slides the loop lock device all the way down to complete the fixation. And at the end we can do a little bit of tensioning of one and tensioning of the other, cut our ends and. When we pass the closed cutter down, we can actually use it as a pusher and apply some additional tension before we cut. And that completes our repair of this capsule using two loop lock devices. This accomplishes two limbs of suture around the capsule in each of the leaflets. We have an excellent closure, low profile knotless devices. So we do not have not stacks, which can potentially be a place where scar tissue can occur. And we get excellent closure with very high strength and security.

Hip Capsular Closure Using the SutureCast™ Suture Passer and LoopLoc™ Knotless Implant&nbsp;

Expanding on the trusted Syndesmosis TightRope® platform, the Syndesmosis TightRope PRO implant is the next generation in syndesmotic fixation. Updated instrumentation and lower-profile implants provide efficiency by design, enabling effective treatment of syndesmotic injuries.

Experience the Syndesmosis TightRope® PRO Difference

Experience the Syndesmosis TightRope® PRO Difference

At the Advanced Shoulder Arthroscopy: The Cowboy Way course, Kevin W. Farmer, MD (Gainesville, FL), reviews the evolving role of reverse shoulder arthroplasty for rotator cuff tear arthropathy, emphasizing that glenoid lateralization, inferior glenosphere positioning, and optimized implant design are key factors in improving pain relief, range of motion, and functional outcomes across both older and selected younger patients.

Reverse Total Shoulder Arthroplasty for Massive Rotator Cuff Tears: When and How?

OrthoPedia: Reverse Total Shoulder Arthroplasty for Massive Rotator Cuff Tears: When and How?

The Arthrex ElbowLOC® positioner is a modular, upper extremity positioner that gives the surgeon the choice of supine, lateral, or supine-suspended positioning for elbow surgery, as well as a wrist traction device for wrist and hand arthroscopy. The ElbowLOC positioner is easy to use and set up, and housed in a space-saving single autoclavable tray.

The Arthrex ElbowLOC® Elbow and Wrist Positioner

The Arthrex ElbowLOC® Elbow and Wrist Positioner

James McWilliam, MD, (White Plains, NY), demonstrates the correction of a type III tailor’s bunion, characterized by a widened 4th-5th intermetatarsal angle, using a more proximal osteotomy on the 5th metatarsal, access at the 5th metatarsal styloid, and fixation with a bevel screw. This approach allows for a greater reduction of the intermetatarsal angle while providing a large surface area for fixation.

Minimally Invasive Correction of a Type 3 Tailor’s Bunion Using a Beveled Screw

Hello, I'm Jim McWilliam from White Plains, New York, and I'm going to talk about minimally invasive surgery on the foot with regards to bunion deformity. So if there's a large intermetatarsal four five angle or if there's significant lateral bowing of the fifth metatarsal, you might want to perform your correction via a more proximal osteotomy. And I'll show you how that's done. And I'll show you an alternative fixation method. Now here we've marked the trajectory of the fifth metatarsal in both the lateral plane and the AP plane. And I'm going to use that sort of as a rough guide for where I'm going to do my fixation. So this is going to be the trajectory of my screw. You can see that instead of being in the high and inside position of a traditional Jones screw, it's going to be going right through the fifth metatarsal Styloid. And I'm going to make my osteotomy where the wire crosses the medial cortex of the fifth metatarsal. So my osteotomy is going to be roughly here more proximal. I might even shift it a little more proximal in that x ray that. So right about there, before the watershed zone of a zone three proximal fifth metatarsal. But we're going to be proximal enough that we're going to get a good level of correction. All right. So we're going to make our incision. I will typically make the incision directly lateral. And that will kind of allow me to do a long oblique osteotomy. I'll use my little elevator. Remember this has the ideal curve to minimally elevate the periosteum dorsally and planoly. To kind of minimize soft tissue disruption but allow enough exposure. All right. So once again I'm going to go straight across just like I have with the other osteotomy. All right. X ray. So I've gone across the I've gone across the entirety of the bone. Now remember there's a declination of the fifth metatarsal. So if I just rotate my hand approximately, I'm going to be cutting distally. And the dorsal cortex. Then I've gone through there. Now, similarly, if I rotate my hand approximately and maybe direct it down just a little bit, I'm going to be cutting approximately. And the planter cortex, you can see I've got my shift there. So this guidewire is a little bit easier to work with. It's the 1.6mm guidewire for the four millimeter beveled screw. And because it's 1.6mm, it's going to be a lot easier to get my direction that I want. So I'm literally starting at the fifth metatarsal Styloid. And I'm going to drive it into the osteotomy line, kind of ideally hugging that medial cortex when I get to the osteotomy. And then we'll check on the lateral and make sure we're in the appropriate orientation there as well. We're pretty good there. So now it's simply going to be a function of moving the metatarsal over and driving the guidewire across the osteotomy and an intramedullary position. So I've got my metatarsal shifted. I've got my guidewire in the right position. So now we're just going to drive the guidewire across. You see how just putting the guidewire in this trajectory across the osteotomy site actually forces the fifth metatarsal medially, affecting your correction. So we've got good correction. We've got good position of the wire in this plane. Let's check the lateral. We've got good correction. You can see I actually cracked the dorsal cortex a little bit with my osteotomy. But we should get good adequate fixation distally without any problem. So now I'm going to use this wire as a guide for my incision. And it just minimizes trauma to the skin and it enhances cosmesis. So I'm going to take the back end of the blade and just push it down. This is an 11 blade. I'm just going to push it down along the guidewire to the fifth metatarsal. So I'm good there. Now we'll take our measuring device. It's beveled to allow us to more closely measure the appropriate depth. We're going to check that the bevel is facing in the right direction. And everything's lined up well. And we still have maintained our medial shift of the distal metatarsal. I'm going to drive this wire out the tip because not only is it our guide for the screw, but it's our provisional fixation and it's just not worth having to do everything over again. We're going to drill over this under fluoro. Not necessarily wanting to go through the medial cortex. All right. We're pretty good there. So if we line up the laser line on the drill with the laser line on the screw, we know what side the bevel is going to be on. Once the screw is buried in the soft tissue, it's just a little visual guide. It only works as long as you keep the driver engaged on the screw. So once the driver is no longer engaged, you're going to have to do it with fluoro. So there's our final fixation our final correction in the AP plane. And there's the lateral.

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What's NewJUL 1

A Deep Dive Into the Variable Angle (VA) Proximal Tibia Plates

What’s New This Week and Prior

JUN 30

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JUN 29

DynaNite® CT for Sternotomy Closure

JUN 28

QuickPass™ FiberTape® Cerclage System

JUN 27

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NanoNeedle™ Scope 2.0 Gains National Spotlight Through

Star MLB Pitcher's Recovery

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