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Impulsionando a inovação com os mais recentes produtos e procedimentos tecnológicos para tratar uma variedade de condições do ombro.

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Há mais de 25 anos, a Arthrex vem mantendo sua dedicação a um único objetivo: responder as necessidades do cirurgião ortopédico, ajudando a tornar os procedimentos cirúrgicos tecnicamente exigentes mais simples, mais seguros e mais reprodutíveis. Como empresa privada, a Arthrex tem um comprometimento exclusivo com o cirurgião ortopédico e os pacientes que tratam. O orgulho que temos da nossa contribuição de importância médica é a essência de nosso comprometimento único e inflexível com a qualidade dos produtos, educação e competência de habilidades cirúrgicas, serviços pessoais inigualáveis da nossa indústria. A experiência que acumulamos e a inovação constante na reconstrução do joelho são redefinidas com o lançamento da nova geração de produtos para reconstrução de ligamentos do joelho e tecnologia de reparo. A Arthrex reconhece e aprecia os comentários e cooperação dos cirurgiões de todo o mundo para a evolução do desenvolvimento desta nova abordagem abrangente para tratamento de lesões do joelho.

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A Arthrex oferece vários produtos novos para a realização de procedimentos abertos ou artroscópicos no cotovelo, incluindo um conjunto abrangente de instrumentos para artroscopia de cotovelo, posicionador de cotovelo, passador de sutura, cânulas, dispositivos para fixação de tecido mole, sistemas de reconstrução de ligamento colateral medial e ligamento colateral lateral para lesões traumáticas e de esporte.

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NanoNeedle™ Scope 2.0
Gains National Spotlight Through

Star MLB
Pitcher's Recovery

The ACP Max™ system provides efficient concentration of platelets and growth factors from platelet-rich plasma (PRP) for use at the patient’s point of care. Expanding on the previous generation of PRP devices, the ACP Max system allows for a larger blood draw and provides increased platelet concentration using a unique double-syringe, double-spin design.

The ACP Max™ system provides efficient concentration of platelets and growth factors from platelet-rich plasma (PRP) for use at the patient’s point of care. Expanding on the previous generation of PRP devices, the ACP Max system allows for a larger blood draw and provides increased platelet concentration using a unique double-syringe, double-spin design.&nbsp;

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ACP Max™ Platelet-Rich Plasma System

ACP Max™ Platelet-Rich Plasma System

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.

Trauma Lower Extremities

Arthrex Variable-Angle Proximal Tibial Plating System

Arthrex Variable-Angle Proximal Tibial Plating System

This video discusses the decision-making process and surgical management options for the treatment of adhesive capsulitis.

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Adhesive Capsulitis: General Surgical Considerations

OrthoPedia: Adhesive Capsulitis: General Surgical Considerations

Gautam Yagnik, MD (Miami, FL), demonstrates a distal biceps tendon repair using the TensionTight™ button.

Distal Biceps Tendon Repair Using the TensionTight™ Button

This is Doctor Janik from Miami, Florida. Today we're going to do a distal biceps tendon repair using the tension tight button to orient you. We have a right elbow. This is proximal. This is distal. This is the radial side and the owner's side. We've marked out the antecubital fossa. And I typically make a transverse incision centered over the radial tuberosity, generally about three centimetres distal to the antecubital fossa. I have the tension tight button that comes preloaded on the inserter with our suture passer. We have our tension tight suture, a Keith needle, our spade tip drill, our appropriately sized reamer, and our seven by ten millimeter biocomposite interference screw. So once we've identified our biceps tendon, I'll get control of the tendon with an Allis clamp. And we're going to go ahead now and whipstitch the tendon using our suture here that's specially designed for the tension type button. And we've brought on our Keith Needle. Go ahead and bring our loop suture through. And you can pass it anywhere between 3 and 6 throws typically allow us to capture the tendon for our final throw. We're going to go just behind our first suture here and lock the suture into place. There we can go ahead and do our final tensioning. And we have really nice control of the distal biceps tendon here. All right. So with some of this excess tendon trimmed off we'll take our sizing guide. And we will size our tendon. And an eight millimeter socket which is pretty typical tends to be the right. So it does not fit through a seven. It goes easy through an eight. So we're going to drill an eight millimeter socket. We're going to go ahead now and load our suture into our tension type button which we've brought onto the field. You can see that it's preloaded on the Inserter with the suture passer already passed through the locking jaw. So we'll go ahead now and pass this suture. And the suture passer helps us to orient the button in the correct orientation and have the sutures passing in the correct orientation through the locking jaw. So you can see the locking jaw right here. So it can pass very easily in one direction but it will not pass backwards. So once we get the suture initially through the button there is a little thicker part of the suture. This little swedge that's coming into our field right here. So we'll go ahead and make sure that we can pass the suture through the button here, getting this little thicker swedge part through the button. And we'll also get a pull just a little more suture through. So we have both ends of the suture coming through the butt. And if we pull perpendicular to the button makes it a lot easier to pass it through the button. So once we get our button set, we're going to go ahead and clamp it here and turn our attention towards exposing the radial tuberosity. So we'll go ahead and identify the center of the radial tuberosity. And I'll kind of if I want to confirm this with fluoroscopy I can go ahead and place this pin. I want to place it by cortically. And once I pass through the second cortex I will stop there. You can use fluoroscopy here. If there's any question I encourage you to do that just to confirm that you're in an anatomic position. So once we've placed our spade tip guide pin, we're going to take our appropriately sized reamer. In this case it's an eight millimetres reamer. And it's cannulated reamer. So it goes right over our spade tip. And then. This will be a unicortical eight millimeter socket. I think it's important at this point to irrigate and remove any bone fragments in order to minimize the risk of heterotopic bone formation. And now we're ready to place our tension type button. So we're ready now to insert the tension type button. I brought this onto the field. It's important to get the orientation correct. We want the locking jaw to be facing up against the the far cortex. And to help us orient, there's a black line on the inserter. So we want this orientation. We want the button to be facing towards the ceiling here. So we'll keep this orientation. So this is the correct orientation. We do not want it going down like this. So we want it coming up like this with the black line facing up. So we're going to go ahead now and insert this into our socket. And then once I get it seated this button is slightly bigger than a traditional tension slide button. So once I get it in the opening I'll go ahead and gently feed it down into the hole, and then I'll give it some gentle taps just until I feel the button get through the cortex. So once I feel it, the button past the far cortex, I'll go ahead and unscrew the back of the inserter, remove the inserter from the field, and then I'll flip the button. So once my button has passed and flipped on the far cortex, I'm able to ensure that it's flipped here by just gently pulling up on these sutures and you can see my tendon starting to advance towards my tunnel. So I'm going to stop here. And just to confirm that my button is flipped on the far cortex, I'm going to get a lateral radiograph here. Here you can see our AP and lateral radiograph confirming excellent position on the button as it rests flat on the far cortex. As we demonstrate here on the live flora we have a very nice position of both our tunnel and our button. So I'll pull tension now on the sutures and advance the tendon to just to the opening of our socket. And at this point, in order to help Facilitate getting our tendon into the socket, we're going to flex the elbow. So we're pulling in perpendicular to our button. And our tendon is going in line and straight and dunking into the socket. So I'm going to go ahead now and do my final tensioning. And as I do this I can go ahead and really seat the entire tendon into the socket here. So sometimes you can help it with a freer. And then you go ahead and then I will also another pearl would be to take each of these sutures and tension them individually, just to make sure you get all the slack out of the system. So at this point, you can see that we have our tendon really well positioned and placed into the to the socket. It's filling the entire tunnel. I can run my freer down. If you would choose not to use a screw at this point, you can cut the sutures and you're done. If you would like to use a screw to either the tendon or further compress the tendon in the tunnel. You can go ahead and do that now. Go ahead and remove your screw. Take a knife here to cut our suture. We have removed our inserter, and you can see that we have our seven by ten millimeter biocomposite interference screw here placed adjacent to the tendon. We have excellent compression of the tendon within the socket. We have easily ten millimeter of tendon in our socket. We have excellent tension here. It's well fixed to the radial tuberosity. And at this point we've completed the procedure. We'll remove our retractors. I like to drop the tourniquet at this point make sure I have excellent hemostasis. And then we'll place this patient into a well-padded dressing. And I like to place the patients into a splint with the arm at 90 degrees of flexion and a neutral wrist rotation for approximately one week.

Distal Biceps Tendon Repair Using the TensionTight™ Button

Seth I. Gasser, MD (Tampa, FL), shares his firsthand experience with the Synergy Power™ system—highlighting how it streamlines workflow within a facility and why it is his preferred powered instrument solution in the OR.

Dr. Seth I. Gasser Surgeon Testimonial: Synergy Power™ System

Speaker  Energy. Power has really changed the way our team works and functions. It's streamlined the work process, including setup times and surgical times with just two hand pieces. It covers our broad range of needs throughout any procedure. It's reliable. Powerful. Versatile. The frequent changes required often during surgery are quick and easy, with a unique design of the hand pieces. It's very easy for the scrub tech to make a quick change. I don't worry about them having difficulty, and my focus is really on the surgery and the patient because I'm confident that the equipment will work as it's supposed to. It provides a balance of comfort and performance. It has a lighter feel. And it's the kind of comfort that really adds up over the course of long, difficult cases. Arthrex has been a leader and innovator as long as I've been in practice over the past 33 years. They've answered all of our questions, guided our setups, trained the staff, and really made sure everything ran smoothly before we started. And this is just another example of how Arthrex has made it easier for me as a surgeon to treat my patients better.

Dr. Seth I. Gasser Surgeon Testimonial: Synergy Power™ System

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.

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.

Arthroplasty Shoulder

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.

Cardiothoracic Surgery

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.

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

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

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

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