Grant Garcia, MD (Seattle, WA), demonstrates the use of the divider cannula and Knotless 2.6 FiberTak® soft anchors from the Remplissage Implant System. The video highlights anchor placement and interconnection through the divider cannula to create a tensionable knotless remplissage construct. Dr. Garcia also shares surgical pearls for suture management, and staged tensioning to reduce the infraspinatus into the Hill-Sach's defect for a secure and efficient instability repair.

Shoulder

Human

Not Hidden

English  - en

video

Tensionable Knotless Remplissage Technique Using the Knotless FiberTak® Remplissage Implant System

Speaker  Grant Garcia here from Seattle, Washington. Today, we're going to demonstrate the Remplissage kit, and we have the 2.6 FiberTaks that we're going to use for the repair. The majority of the kit you're going to see in the video demonstration, you have a new handle system, then the divider cannula and then the removable divider. Okay. So you can see here we have a left shoulder. This is the lateral positioner we're in. You can see that here we have a labral tear which we're going to fix shortly. So anterior labral tear posterior labrum actually is in a pretty good position. We're using the PanoScope so you can see the views a bit better as well. So now we're going to do our Remplissage anchor. We use these two needles to mark out our trajectory for our anchors to make sure that we have the appropriate infraspinatus bite for the Remplissage. And then in the middle, we're going to split down here and use the divider cannula to place both the anchors safely through the cannula and allow us to interlock that infraspinatus down. So this is the new divider cannula system. This is really nice. It's got a sharper tip trocar. But this will not penetrate through the capsule. And you're going to enter this in and sweep. So the trick here is to sweep. You can see the tissue being molded. Speaker  You will not engage any of the Bursa. You will not engage the deltoid if you do this. So it's really important here to highlight the orientation of this because the cannula is not a perfect circle. It's an oval. So now we've turned it locked it into the skin here. And you can see the way it's being held. This is excellent. Up and down is going to be the where the cannula is placed on the inferior superior aspect. Again we're in lateral position. This is where we're going to lock in our sutures. This allows for suture management. So it's a really nice cannula system specifically designed to make sure that Remplissage is easier for the user. So here we can actually place this removable divider in. And you can see the way that it's angled the divider. So you can easily place your anchors through it. So the nice thing about this handle is ergonomic. It's got a place for your thumb. So you can help you get through the infraspinatus. So it just goes right down there. It almost actually gives you the position that you want to go. And then we're going to just gently push this in. This is quite sharp as you see. So we've got good space there. It goes in very, very easily. So you have an option obviously of doing this percutaneously. Speaker  But I don't find that necessary in this scenario. What we're going to do is going to go right on the margin of that Hill-Sachs. And then we can just place the anchor and you already have the first one set. Okay. So now we're going to place the first 2.6 Knotless FiberTak. You can see there's a laser marker, so you don't have to go all the way down. So you can mount that in. Excellent. And you can see we have a really nice view here before I take out any of my Cam systems actually engage the anchors. And we're talking on this pretty hard. So it's nice. It's set really well. So we've removed the handled guide system. So one trick here is not to actually push too hard on the suture because of this unique cleating system. If you push too hard you actually will perform a Remplissage with the cannula in. So you want to just relax here, put this amount of tension and then you can actually nicely lock this in, which is really unique system. So now you've locked that in. So now we can place our second one. Okay. So we placed our first anchor again. The key here is inferior anchor first, then superior anchor. You can see we have a really nice view superiorly. Speaker  So we're able to place this without any issues. So watch as I place this through the cannula. You obviously don't want to go through the same hole that you just did. But because of the uniqueness of this divider, you can go through the superior hole and you have no concerns about damaging your sutures. Okay, so now we've placed the dilator and guide in for the superior anchor. You can see we've got good spacing. You'll make sure you have adequate enough space in at least one to 1.5cm, and you want to span the entire Hill-Sachs at least one to 1.5cm. The nice thing is the footprint on these anchors is quite small, so you have a little bit more leeway here, and you can see where the fish mouth again and again. What I'll do is I'll just push this fish mouth in a little bit better. So you can actually use it as traction and see better. And then you put your fish mouth. And we're just going to make be aware of our other anchor, which were plenty of space. Okay. And then we're going to place it, make sure we have a comfortable hold. And now before we remove this handled guide system, I'm going to load the anchor. As you can see they're loaded nicely. We can remove the guide system. Speaker  And now the space opens up again. And then again. Similarly you're going to cleat this. Great. So now we have our anchors placed for the Remplissage. We have enough space between the two. What I will do is I'll actually interlock the anchors for the Remplissage. The key here is to not fully tighten it, because you can make the posterior aspect more tight and or the entire shoulder more tight and more difficult to fix the anterior labrum. So you'll see the uniqueness of this cannula system. So now we can remove the divider. Okay, so I'm going to take the repair stitch from the superior anchor, and I'm going to lock it. And you can see that assistant is an excellent job of already locking the whole system from the inferior anchor. So they don't get pulled together. So we have our loop here, similar to having any of these knotless options. And then we're going to pull the repair suture through it. And you're going to go to the laser mark. Now we have our pull stitch. So we're going to slide this and guide it all the way down. And you're going to wait till you just see the capsule pucker just the tiniest bit. So right there we're starting to see it pucker. So we're going to stop. Speaker  And then this we're going to cleat out of the way. And now we have the repair stitch from that anchor, the superior anchor. And we're going to do the interlocking mechanism from the inferior anchor. To allow us to do our double knotless Remplissage. So now we've cleated these stitches. We have not final tightened. As you can see here, it's essentially puckering. This actually is helping that humeral head pull back. And what we're going to do now is go and finish our bankart repair. And then we're going to come back and final tighten. Okay. So we did most of our Remplissage. Then we went and completed our bankart repair. You can see here and retension it. So we have a nice labral repair there. So you can now release the lateral traction. And we're going to go back and we're going to finish up our Remplissage. So we're going to just pull some of the tension out. You can see it's sliding really nicely. And then we're going to repeat that. And you can see even if we pull this away, we've taken all the traction off. This is not going anywhere. So we've final tensioned here. And you can see how this nicely centered it. Now you can actually see this a bit better. It really pulled it back nicely. Now we have our Remplissage completed.

Tensionable Knotless Remplissage Technique Using the Knotless FiberTak® Remplissage Implant System

The Rotator Cuff Express Instrument System was designed with ambulatory surgery centers (ASCs) in mind, featuring a single-level, low-profile, and customizable layout that houses the latest instrumentation for Arthrex’s next-generation implants. Ideal for smaller surgery centers with cost and space concerns, the case also complements larger “master sets” at busy hospitals and is configurable to suit your needs and preferences.

Arthrex Rotator Cuff Express Instrument System

Arthrex Rotator Cuff Express Instrument System

This video discusses the decision-making process and surgical management options for the treatment of tibial plateau fractures.

Trauma Lower Extremities

Hidden

Tibial Plateau Fractures: General Surgical Considerations

OrthoPedia: Tibial Plateau Fractures: General Surgical Considerations

Stephanie Pearce, MD (Jacksonville, FL), demonstrates an osteochondral allograft transplantation using the 20 mm precut OATS® kit.

Knee

Osteochondral Lesion Treatment With the 20 mm Precut OATS® Kit

Speaker  Hi I'm Doctor Stephanie Pierce from Jacksonville, Florida. Today we're going to be working on a 20 millimeter osteochondral allograft transplantation with the Arthrex 20 millimeter Osseo pre-cut kit. This is a convenient option for this size of an osteochondral lesion. In the kit is the dual tamp dilator. This tool is very intriguing. It has the dilator and measuring guide directly on one end. You can see these measurements here allow for easy identification of the depth of the lesion to match your graft. Additionally, there is a guide pin cannulated slot, so this will slide over the guide pin in the center of the lesion to allow for consistent and reliable entry in a seamless fashion into the lesion itself. The Tamp on the other end allows for easy entrance of the OCA graft into the lesion to allow for smooth tamping and flush fit at the completion of the case. So this is the graft delivery tube. This allows for arthroscopic insertion and completion of the OCA allograft, and you can see the dual Tam dilator easily fits into the tube to allow for ease of dilation during the procedure, as well as ease of graft, delivery and graft entrance. So as you can see, we've started our approach. We have a midline incision with a medial parapatellar approach. Here you can see I have marked the superior medial corner of the patella in order to allow for appropriate tensioning of the joint capsule. Speaker  At the completion of our case, after the graft is in to allow for appropriate biomechanics of the knee joint at the end of the Osseo grafting. And here in the center of our medial femoral condyle, we see our lesion. Now this lesion measures approximately 17mm by 19mm. So it's quite large really giving a great option for this 20 millimeter pre-cut OCA graft kit. First I like to take the dual Tam dilator. And we can use this as a measuring guide. It has these beautiful measurements here. And you can see it runs really nicely on the cartilage. So you can find the best position to get the best read. Right now, we can see that the 20 millimeter guide will cover the entirety of our lesion, but is not too large for how large our lesion is. So this is a great fit. Finding the center of this lesion is important. That's where our 2.4mm guide pin is going to come in. And this dual tamp dilator allows us to get right in the center of our lesion and come in directly in the center with our guide pin. You need to enter just enough to get a good hold. And you can see that guide pin is going to be aligning nicely for our reamer. As we're getting ready to ream, we want to ensure to be using fluid to minimize the bone death. And heat damage to the recipient site. Speaker  The nice thing about this reamer is that it has measurements on the reamer itself. So you can see we're coming about to a depth of eight 8 to 10mm, which is ideal. So we'll stop here. Now the reaming is done. We'll clear the debris out of the site here. So after cleaning all of the reaming you can see we've marked the 12:00 position, which is really important for orientation. And in comes the Cannulated dual end tamp also working as our measuring device. So we can see right now it is at ten millimeters at the 12:00 position. And we can get all of our measurements around at each of the 3:00, 6:00 and 9:00 positions. This is one of the strongest pearls that I can recommend, is making sure that we have those precise measurements at each of those corners. That allows for smooth contouring to recreate the articular surface at the contoured shape of the patient's host recipient site. That's going to allow the best match for the Osteochondral allograft to help minimize wear deterioration and improve incorporation and integration of your OCA. So now we've taken the guide pin out and we're going to leave the dilator in place. This will help protect the recipient site, but it will also help create an easier passage of the OCA into the recipient site at the conclusion of the graft preparation. All right. Speaker  So now we're on our back table and we're working with the graft itself. So this is a really nice option because this comes pre-cut and delivered from the package exactly like this. Other than the fact that I marked our 12:00 position. So this is how it is out of the package ready for ease and use. The first thing we want to do is measure the depths. So these need to match. So I like to use a clock face to do this. Some prefer a compass rose, but for me, measuring the 12:00, the 3:00, the 6:00 and the 9:00 are crucial to allow for appropriate contouring to match the host site. That way, there's the least amount of degeneration of the osteochondral allograft. So as we're doing our hour measurements, I like to make sure I have two hands to guide our depth to be as accurate as possible. So the 12:00 is at ten millimeters. We'll rotate to the 3:00 position and that's going to be at nine. Our 6:00 is at 11 and then our 9:00 is also 11. Beautiful. And then I like to connect these. This helps guide my saw blade to ensure an appropriate contour which increases the graph matching reliability. Very rarely do these come exactly equal all the way across. So having this reliable method to create a perfectly matching graph to the host makes this a much more streamlined procedure. So now you can see we have measured the depths of the graft along the various clock face measurements. Speaker  And this allows for an appropriate matching for the contour with the depth of the lesion that has been taken. So I like to use stable towel clamps to hold our graft. So now that the graft is held securely with the towel clamps, it's available to allow for sawing to taper this to the exact size and depth that's needed. Once again, very important to ensure fluid is running during the sawing so we can minimize cell cell death and encourage bone to bone healing and integration. As I'm positioning the graft, I like to have the largest area that needs to be removed closest to me. This allows for the least amount of sore passes in order to have a more efficient cutting method. The graph is toggling, so I readjusted the clamp so that it will have the least amount of movement as the sore is coming across. You can see it's much more stable. Another tip is you can take either the edge of the saw or the rongeur to bevel the edges. That will allow for easier entrance into the dilated recipient site. Now our graft is ready to be soaked with ACP or autologous fluid of your choice. All right, so now we're back to our recipient site. We're going to remove the dilator and this is a key Pearl is to. Speaker  Now lay down a suture tape. The suture tape gives much more control of the graft during insertion to allow for any readjustments or. If you don't like the position of the graft or the depth of the graph, you can take the graph completely out without causing any damage to the cartilage. And now we will insert the graft matching the 12:00 positions. And we'll have our Tamp ready. This is going to be a good tight fit. It's going in really nicely. So a couple of light taps as you're moving around. Always dispersing the forces is really important. Remember remember the chondrocytes are are alive. So you want to have the least amount of traumatic damage to them as possible. And then once it's seated, which is when seating really nicely, I like to take a 15 blade, and this helps to get the fine tuning for the final position to really maximize the cartilage matching for the contour. These are very small slivers, if you will, especially since there's no matching with these pre-cuts. Sometimes you need just a little bit of fine tuning to make it perfect, but it still is a wonderful option. At a faster rate to be able to create a beautiful matching graph with a gorgeous contour matching the patient. And there you have it, a 20 millimeter osteochondral allograft from a pre-cut plug using the Arthrex 20 millimeter pre-cut OCA kit.

Osteochondral Lesion Treatment With the 20 mm Precut OATS® Kit

Saqib Hasan, MD (San Francisco, CA), demonstrates a percutaneous approach to pars fracture fixation using the fully threaded spine compression screw with optional endoscopic debridement of the fracture.

Spine

Percutaneous Pars Fracture Fixation

Speaker  Hello everyone. My name is Doctor Saqib Hassan. I'm from Golden State Orthopedics and Spine. And today we're going to be discussing how to perform a percutaneous pars fracture fixation with or without debridement of the pars fracture depending on the chronicity of the pars fracture. So the first thing we want to start off by doing is make sure if we're going to be using fluoroscopy and not navigation, is to make sure we have excellent fluoroscopic imaging of the pars on both the AP and lateral plane. Again, without navigation, this procedure can be very challenging. If you are not sure where the starting point is for your incision. Another important part of positioning the patient for this procedure is to ensure that the patient has the proper amount of kyphosis of the lumbar spine, because we all know that patients who have higher incidence of pars fracture have been known to have a higher pelvic incidence and have more lumbar lordosis, which can make this procedure more challenging if you're trying to fire a screw with significant lordosis. So again, what we did in this particular specimen is that we've added a lot of bumps to increase the kyphosis. And if you were to do this on a patient, I would recommend using a Wilson frame instead of a Jackson frame to avoid the lordosis. So let's start by actually marking. That's going to be the position of our screw. Okay. All right. We're going to mark that. Okay. So as you can see on my AP radiograph, what I did is I marked a starting point from the bottom of the lamina going across the pars bisecting the pedicle. Speaker  I'm going to actually make it right in the middle of the pedicle. Maybe angle a little bit medial. So you can see that in this particular X-ray I'm bisecting the pedicle. I'm not too lateral to the pedicle. So my screw is going to have nice fixation in the pars. And I have a good starting point on the lamina with the inferior articular process. So we're going to take that incision. We're going to bring it all the way down. Okay. And then I'm going to do a similar one for the opposite side. And then we're going to do that right there. Again. That's pretty good. We're on the inferior articular process lamina junction. And I'm bisecting the pedicle. I'm going to mark that one. I do the lateral line because I know that my trajectory is going to be kind of like this. So I'm going to use this angle and then I'm going to actually meet in the middle right there. I'm going to try this one first. So I'm going to go mark the angle hit spinous process there. Okay. I have the right trajectory on the AP. I have to make sure my lateral is good to make sure I land on the pars. Okay, so that's pretty good. That's right in line with our pars. So now I'm going to have a good approximation of where I'm going to be. Speaker  I can still make some micro adjustments. So it's important to understand that it's okay if you're not perfect on the first go. All right. So we're going to swap that out. We kind of know where we're going to end up being. We know that we're a little bit lateral. So I'm going to watch that again. I'm going to angle there. I like my position on the lateral. I'm going to go more steeper. All right. I like to typically now that I have my position I'm going to mount this a little bit. Okay. Let's get that in there a little bit more. Okay, I like that. So what I'm going to do is I'm going to drop my hand. You see my, my trajectory, obviously it looks good. It's just micro adjustments. We're going to we're going to pull this back a little bit. So you can see that I have a good pars trajectory. You can see that I'm bisecting the pedicle and the key is on the AP. You want to stay lateral to the medial particular line. Because obviously if you're medial to the medial particular line you can have injury to the traversing nerve root. I think I'm going to have good fixation there. Now what we're going to do next is we're going to take our wire out and measure. Now this part can be tricky. Obviously, if you're on navigation, you can do an intraoperative measurement of the navigation. Next we're going to do is we're going to insert our dilator. Speaker  Sometimes you can experience a little resistance. Now we want to measure the length of our wire. And you can see I have this drill guide, which is very helpful. The point of this, of this drill guide is to be able to catch the lamina. Okay, you can see that this drill guide has two tines. And the point of these tines are to be able to have some grip of the lamina. So the tendency can be when you're doing this drilling is to skive this way or that way, but the tines actually help you quite a bit in making sure you you have the appropriate trajectory and you don't lose that trajectory when you're drilling the path of the guide wire. So we're going to do that again. We're going to take our tines. We're going to put this in here like this. Again, you have to kind of rotate to get through because of soft tissues. Now I'm in my position. I'm going to always drill on the lateral okay. Because I don't want to skive. The tendency is to skive superficial or deep. And we're measuring on our guide. Our measurement is showing that we are approximately 35. So I'm going to on the side of 36 because I think we have our wire just a little bit shorter. And a nice little trick to do is to make sure that the tines of this soft tissue drill guide are on the lamina. You can do a gentle tap. Speaker  And then again, we can just double check our length. We can see I like that position. I think 36 is going to be perfect. Okay. And now we can commence with our drilling. Now one little trick that you have to remember is that obviously we know that everything we're doing is based off this guide wire. You can see the guide wire is not sitting in the middle of the hole. So I like to kind of just make sure we adjust this so it sits right in the middle. You see now it's perfect. And if you pay attention to the last AP, the drill guide was a little bit off, but this is how you can make sure you're staying in the center. Because if it's in the center, you know that you're drilling right in line collinear with this wire versus off axis if it's like this. So a small tidbit, but it helps a lot to make sure you maintain your position. Okay, I like my position there and you can always do some minor corrections if you need to. Although I don't recommend too much correction because then the guide wire might catch. So I like my position there. I'm going to start right now we're at 36, but I think we're closer to 40. So I'm going to take a 40 on this one. Yep. I like that a 40. I'm going to take that at 40. Typically when you are measuring the width of the pars screw, I like to use a preoperative CT to see about how wide that pars is. Speaker  The average is about anywhere from 4 to 5mm. In some patients you might have six, but I think generally 4 to 5 is the average. So we're going to be taking a four by 40 millimeter screw. Okay. Now here's our screw. Nice. I'm having a nice bite. I already feel the bite here in the compression that's happening. I'm kind of at the end point. I feel a lot of resistance. You don't want to go too far. Okay. And then now that we're done. Pull that out. So you can see now that we're done putting our placing our screw, we can pull our guide wire. That looks very nice. I like that I didn't have it too deep or I can still retrieve if needed. It's right down the middle of the path and that looks beautiful. You can see we bisected the pedicle. I like my position. It's right where the pars fracture would be. One other thing we want to touch upon before we conclude is what you would do if you had a chronic pars fracture, the steps would be a little bit different. We walk through the instrumentation part, but what I would typically start with is I would actually start by localizing on the pars with my endoscope. So again we showed the direction of our pars screw. So what we would do is prior to actually beginning the instrumentation portion, I would localize to the pars fracture right here. Speaker  And it's important that you debride the edges of a of the chronic pars fracture. Because typically you're going to find a lot of scar tissue within the fracture site, which can impede bony healing. Typically when you have fracture gapping and it's a chronic pars fracture, it behooves the surgeon to perform a debridement. And typically if you want to perform this the most minimally invasive way, I would obviously do this. Endoscopically we have patients who are high level athletes who are trying to return to sports. It makes the most sense if you're going to do minimally invasive pars fixation, also do a minimally invasive endoscopic pars debridement right here. So we already put the screw in. So what we're gonna do is we're going to debride that area. And hopefully we're going to be able to see the position of our screw in a nice position. So what I'm first going to do is draw a line that is just parallel to the pars fracture. So I know that my pars fracture is somewhere around here. And because we're just going to go direct onto the pars fracture there's not much more that needs to be done except just mark how lateral you're going to be. That's typically where you'd find the pars fracture. I'm going to make a mark right there. And then I'm going to take my incision. Okay. Get this needle in here. And I'm going to take this here. And I'm going to just do a little soft tissue dissection again. Speaker  And let's just make sure we like our position on the pars. That's it right there. Okay. We're going to hold that position. Okay. And we're going to go right there. Yep. You can see on the X-ray I'm right where the pars fracture should be. Okay. So if the AP in the lateral all line up, then all means they'll have us go a little bit deeper. I'll see that PA screw. Okay. And you can actually see this is medial okay. As I walk down here it's lateral and you can I'm falling off the edge here. So my part is right here. This is the pars. Obviously there is no pars fracture in this in this specimen. And we're going to create one. But the idea is that when I land here you would see a lot of soft tissue. You would feel bone here bone here and you'd feel soft tissue in between because typically there's some fracture gapping there. So you can see our part fracture would be here. We can start to see some of the screw that I don't want to drill out the screw, but you can see the screws coming this way. In that trajectory, you can actually follow the screw. It's actually coming this way towards the top of the pars. And this is our trajectory. You can see all the threads of the screw there. Essentially when you're doing this, the workflow is for chronic pars fracture. Once we have debrided the pars fracture, we would then have the scope holder kind of look at the fracture site. Speaker  And then what we would do then is all the steps we performed before, whether doing it with fluoroscopy or navigation, you would then fire the guide wire first, and then you can drill over that. And you can actually directly visualize your drilling as well as your guide wire placement. So it adds that extra level of security knowing that you're in the right spot. You know, we're very close to neural elements here. You want to be very, very exact and precise when you're doing this procedure. So I always will start with my debridment and make sure I know where my pars is prior to putting the screw in, I do put some biologic bone graft into this defect. It helps that there's bone graft into the defect prior to adding the compression screw, and it will help to compress some biologics within that pars fracture zone. Another important element is to make sure that when you're debriding, to make sure you have bleeding bone at the site of the pars fracture, that also encourages bony healing. As far as post-operative protocol for the patient, we typically will place the patient in a LSO brace and limit lumbar extension. For the first six weeks. We will start gentle physical therapy at six weeks with avoiding hyperextension or extension exercises. And typically the return to play can be anywhere from six months to a year for most active athletes.

Percutaneous Pars Fracture Fixation

Michael A. Zacchilli, MD (New York, NY), demonstrates an all-inside arthroscopic medial meniscal allograft transplantation (MAT) technique with the SutureLoc™ implant for root repair and FiberStitch™ 1.5 implants for capsular fixation.

All-Inside, All-Arthroscopic Meniscal Allograft Transplantation

Speaker  Hi, this is Doctor Michael Zukile from New York. Today we'll be following a case of a medial meniscus allograft transplantation utilizing an all arthroscopic all inside technique. This on the back table we'll see our meniscus prepared with a FiberLoop SutureTape for both the anterior and posterior roots. On the anterior root that's utilized for eventual all knotless suture fixation. On the posterior root, this is a ripstop, which will help support our fixation with a SutureLoc device at a position between 15 to 20mm from the posterior root. You'll also note our SutureTape passage stitch, which will be utilized during graft passage and then sacrificed. So we're going to orient ourselves to the patient here. This is a healthy patient. Great knee. We can see the cartilage surfaces are intact. Importantly when we're considering to do a transplant. We've already checked and made sure that we're ligamentous stable. The ACL is in good condition. Again, no full thickness defects in this case. This patient is status post a complete meniscectomy. And we've already gone ahead and cleaned up the residual meniscus, leaving only that 1 to 2 millimeter rim Circumferentially that's going to be really important to maintain that because that's going to maintain our circumferential integrity and our hoop stresses after our transplantation. We'll also expose both our posterior root and our anterior root. We'll notice our posterior root here. Very importantly just posterior to the medial tibial spine. Speaker  And the position of it is actually anterior to the PCL. Common error would be to place this too medially in the knee. We want to make sure we're meeting the anatomic position. Similarly in the front we follow the anatomy of the native meniscus here. And we're going to just look down right over the top again for this particular technique. The whole key is maintaining ideally the native root insertions. We're going to fixate those first. And that's going to create our hoop tension. And so following those native fibers we're going to carry those down into the anterior tibia. We've completed a fat pad resection in this area. And we can really note how anterior that root falls relative to the ACL, really almost directly in front of the ACL itself. We're going to create our knotless anchor fixation point in a position just lateral to the most medial extent of the root. And so we've demarcated that here. And that will allow us to adjust the tension on our graph to account for any size differential. And then finally, again this rim is completed. Expectation for our traction stitch will be placed at a position roughly 15 to 20mm from the posterior root adjacent here. So we have our root guide in place anatomically just in front of the PCL. We want to make sure we're drilling a relatively high angle, usually somewhere around 80 degrees or so to make sure we're not skiving, and that as this exits into the knee, it's centered in the footprint there. Speaker  At this point, we've retrieved the wire loop. We're going to go ahead and exchange that for a FiberLink allows for a little bit smoother passage of our SutureLoc anchor. And then we'll go ahead and use that FiberLink to pass the SutureLoc in a standard fashion. I'm going to want to watch our anchor sink below the subchondral surface. And once in position, we'll go ahead and deploy that and achieve subchondral fixation on that cortex. Pull ourselves back and ensure a solid fit. And we're secure for that posterior root. So coming through that same PassPort, we'll bring our ZoneNavigator and this will be to place our traction stitch again a position about 15 to 20mm from our root. We know that as long as we're behind the semimembranosus here, this can be placed percutaneously. And it's one of the key factors that allows us to utilize a fully percutaneous technique for this case. We can palpate the posterior medial tibia, and as long as we're behind that semimembranosus, we're safe. And this obviates the need for a posteromedial incision completely. We can retrieve that transcutaneously. And here we have our traction stitch. So at this point, we're going to manage our sutures and remove the PassPort to allow for graft passage. Speaker  My knotless anterior anchor is going to go over here to my assistant, my passage traction stitch there. And I'll maintain control here of our SutureLoc. And we'll go ahead and take that PassPort out. Now as we do that, we're going to independently control each of these. Making sure we have all of the involved stitches and we're independently controlling those with snaps externally. Take our traction stitch. And that leaves us with our SutureLoc centrally and these are all independently divided. I also want to make sure here that the Arthrotomy is big enough to allow for the passage of the graft. We should be good in this case. So at this point, we're going to initiate our posterior root fixation. Utilizing the suture locks. The repair stitches will be placed in a Mason Allen configuration around our preexisting RIP stop. That's going to maximize the strength of our repair configuration and also improve the overall tear out resistance for the root. We know that our posterior roots and transplants fail most commonly in this location. We want to maximize that. So at this point we're going to manage our traction stitch, rotate the graft to match the patient configuration. Our traction stitch is coming posterior posterior medially rather. And our previously placed SutureTape from our meniscal repair with the ZoneNavigator can just be placed in this position. And that's all we need to do there. Speaker  At this point we're going to place our passage stitch placed a barrel knot into our suture repair stitch here. We can use that to dilate our capsule before passing the traction stitch and just tie a simple knot here. Now, with the graft adjacent to our root, this is a good time to finalize our repair stitches for the SutureLoc, and we'll do that one at a time here. So for graft passage we're going to maintain the position of our graft and then alternate tension on our SutureLoc repair stitches doing our deep blue mason Alan first, followed by the white and alternating fashion. As we do that, the traction stitch will maintain by my assistant here right before we actually bring the graft in all the way, we want to make sure it doesn't flip. As you can see, it's trying to do that here. Maintain that position and tuck it behind the condyle can assist there again alternating our blue and whites. And then once we're close should just slide on back there, apply final tension to the suture locks and tuck that anchor in before we pull full tension on our traction stitch. And we can really see the stability of that fixation. If I bring my probe in between the rip stop and the Mason Allen configuration. So we can see here anatomic position, excellent tension with that SutureLoc device. Speaker  And this is really where the key to this comes into play. Because as we're going to establish our anterior fixation with our knotless device, we'll be utilizing the native hoop stresses of our graft to set our attention. And so now we can see we've converted our posterior fixation SutureLoc. We have our traction stitch in place, and we've converted our anterior knotless anchor here and secured it provisionally. The goal here is that that's got some ability for modification. And we can set native root stresses or hoop stresses rather. And you can see here that that meniscocapsular junction looks just like a bucket handle tear. And so the hoop stress set between our roots for this graft match the native capsule nicely. And at this point we're just going to go ahead and complete our peripheral fixation, our meniscocapsular fixation with our FiberStitch. It's important to understand when you're using these FiberStitch is that they act both as a fixation technique, but also as a reduction tool. And so we want to identify our native position, really reduce that meniscocapsular junction. And I like to set my capsular stitch first. This sets the height of my transplant right at the edge of that residual. And then again identifying the position of our graft. That's going to reduce nicely there. Placing this posterior medial stitch first is really important because that sets the tone similar to closing a closing in skin incision. Speaker  We want to reduce equally across the full length of the meniscocapsular junction. We'll go ahead and tension this provisionally and then finalize our tension. And here we can see that FiberStitch we're going to complete similar fashion again noting there's almost a native reduction of this graft to the patient's capsule. And so we really know we've set that hoop stress with our root positions correctly. At this point. The traction stitch can be removed and that can be completed fairly easily. And so now, free of any posteromedial incision, we're prepared for a peripheral fixation just as if it was a bucket handle. And here's our final construct of our all arthroscopic all inside meniscus transplantation. You can see we've augmented the initial FiberStitch circumferentially with additional meniscocapsular stitches. We have a nice stable repair, our reconstitution of our flounce sign. So our hoop stresses are great. And we've converted that knotless anterior root stitch here as well. We can see that root reconstituted right in front of the ACL footprint. So this is anatomic. And we'll go through just an anatomic reduction in a range of motion. And we'll identify how that stays inside our joint. We don't see any extrusion. Nice and stable repair all through range. And all accomplished without an additional posteromedial incision and all with suture fixation.

All-Inside, All-Arthroscopic Meniscal Allograft Transplantation

Michael A. Gallizzi, MD (Vail, CO), discusses a salvage medial branch transection (MBT) procedure as a definitive solution for a 36-year-old female with right-sided low-back pain after two previous rounds of radiofrequency ablation provided only temporary relief.

MBT as a Definitive Solution After Temporary Relief From Radiofrequency Ablation

As a medial branch. Transection procedure continues to grow in popularity. More and more patients are going to present to your office that have had previous radiofrequency ablation. That may not have lasted very long for them. So essentially, a lot of these patients will continue to have repetitive rfas, and their effectiveness continues to get shorter and shorter over time. But they still were effective for the time that they had the ablation. What a salvage medial branch transection can do is bring that effectiveness back to them as a definitive procedure for their back pain. Today, we're looking at a 36 year old female soccer player who had continuous right sided low back pain. She had two previous rounds of radiofrequency ablation. Unfortunately, the radiofrequency ablation on both of those rounds lasted less than three months, but it did hit the spot. Typically, these patients have had some success with the radiofrequency ablations. The pain relief just doesn't last. And for these patients, a salvage medial branch transection is a great option as a definitive procedure for their back pain. One thing to check radiographically with these patients is to make sure that they don't have any instability on flexion, extension, x rays, or any other contraindication that would tell us a medial branch transection shouldn't be performed for this patient. What I look for is patients that have a stable spine, with no evidence of slipping more than two millimeters on flexion extension x rays. The diagnosis for these patients has typically already been proven with successful medial branch blocks and or radiofrequency ablations that have treated that area, but the ablation has just not lasted. Many times, these patients have had multiple rfas over years and months, and they just keep going back for this short lived treatment. The revision medial branch transection is a great salvage procedure to be able to make that feeling of pain relief permanent. When I'm performing the treatment for a medial branch Transection revision. What I want to make sure you understand is how much scar tissue is going to be present from the previous radiofrequency ablations. The ablations have essentially caused a huge scar ball to form by that thermal injury to all the surrounding tissue. So really identifying the floor of the transverse process and moving out laterally to the accessory process as your lateral extent. Now what you're going to do is move both cranial and caudal on that transverse process to be able to start peeling back all that scar tissue. What you really want to avoid is going lateral to the accessory process, because in that area you're going to start getting the lateral branch that innervates the deep paraspinal musculature. You also want to avoid going to cranial or caudal, as we don't want to enter the neuro foramen, where the exiting nerve roots are coming out, as that can cause a neurologic injury. So being very careful on palpating and always making sure you're on bone is very important to a revision. Medial branch transection. Once your exposure is complete and you can adequately visualize the landmarks that we just discussed, what you really want to do is find that medial branch coursing out of the cranial neural foramen, down in between the accessory process and the lateral aspect of the facet joint. What you want to do next is find that branch, transect it with either punch or scissors to be able to completely renovate the medial branch, and then once that is complete, you take your high frequency RF probe and essentially denude all the neural tissue from the lateral facet wall all the way to the accessory process. This patient had an excellent clinical outcome since the two week post-operative period. They have been pain free, and she was able to return to all her mountain athletic activities without any recurrence in her pain. Postoperatively. What we do is we do put in some nylon sutures that we leave in for about two weeks. Well during that time period, we let them get back to their ADLs and walking, but really don't let them push any athletic activity. Once the sutures out and the skin has completely healed, we begin a scar massage routine in physical therapy to be able to get the soft tissue planes to slide. And then we get them into sports specific physical therapy as needed, to help them optimize whatever sport they want to get back to. Being able to offer your patients a salvage for a previous successful RFA that just isn't lasting, allows them to get back to their activities in less than two weeks. Really gives a motion preservation procedure that allows them to continue to avoid any talk of fusion. This is a low risk, high reward offering in the setting of a failed previous RFA and allows immediate return to sport and improvement of their spinal pain and low back pain without any talk of a spinal fusion.

MBT as a Definitive Solution After Temporary Relief From Radiofrequency Ablation

Designed to be deltoid-sparing, the Arthrex Anatomic Proximal Humeral Plating System delivers versatile fixation with 7 plate lengths (92-265 mm) to address a wide range of fracture patterns. Featuring variable-angle locking screw options, KreuLock® technology, and integrated FiberTape® cerclage button capability, this system is designed for strength, flexibility, and efficiency.

Arthroplasty Shoulder

Arthrex Anatomic Proximal Humeral Plating System

Speaker  The Arthrex Anatomic Proximal Humeral Plating system is designed to be a limited contact deltoid sparing plate, aiming to avoid taking down the deltoid insertion on the humeral shaft during implantation. This plate features variable angle locking and compression screw technology to provide a streamlined, reproducible reconstruction of proximal humerus fractures. The proximal humeral plating system includes 14 site specific anatomic proximal humeral plates. Seven plates for left shoulders and seven plates for right shoulders. Plates are three whole to 15 whole, with length starting at 92mm and ending at 265mm. Anatomic plates feature a divergent screw pattern with a choice of 4.0mm cancellous or 3.5mm reinforced variable angle locking or KreuLock screws in the head, and a five millimetres compression slot in the shaft, 3.5mm cortical screws are accepted in the first five screw holes of any anatomic plate. Further, distal OR plates that are seven hole or longer screw holes, except 4.5mm cortical screws or 4.5mm FiberTape cerclage buttons. The Arthrex Anatomical Proximal humeral plate is specifically designed to be deltoid sparing, curving anteriorly before the general region of the deltoid insertion on the humerus. Suture eyelets in the bend are intended to assist with soft tissue repair. The proximal humeral plating system requires two instrument trays for clinical use. The designated proximal humeral tray, as well as a general instrument tray. Begin the procedure by using the T 15 screwdriver to secure the alignment guide to the plate. Confirm the plate position by placing a two millimetres k-wire through the hole on the superior aspect of the alignment guide. Speaker  Using the 2.5mm drill guide and 2.5mm drill bit. Drill through both cortices of the oblong hole in the shaft of the plate. Use the depth gauge to determine appropriate screw length and insert a 3.5mm cortical screw. Next, confirm appropriate plate positioning by placing a 1.6mm k-wire through the drill guide. Confirm the k-wire position using fluoroscopy. If using the 3.5mm reinforced variable angle locking OR KreuLock screws, insert the 2.8mm locking drill guide or use the freehand drill guide if using a 4.0mm cancellous screw. Use the 2.5mm instrumentation. Ensure that the drill does not perforate the far cortex. Kreulock provides interfragmentary compression through a variable thread pitch of the screw. The lateral plate will allow for screws to be placed up to 12 degrees radially. From the central axis of the locking hole. Insert the desired screw using the T 15 driver. Repeat the previous steps for the remaining proximal locking screws and confirm appropriate fixation and reduction using fluoroscopy. If additional compression or plate reduction is needed, distally insert the reduction bolt by cortically through a locking drill guide. Thread the compression onto the reduction bolt until the nut contacts the drill guide. Continue turning the nut clockwise until the desired reduction is achieved. If desired, FiberTape. Cerclage. Sutures may be applied prior to placement of the plate or directly into the plate construct using the 3.4 or 4.5 millimetres cerclage buttons inserted into a plate shaft. Screw hole. Additionally, soft tissue may be repaired to the plate using any of the peripheral suture islands.

Arthrex Anatomic Proximal Humeral Plating System

John A. Ruder, MD (Orlando, FL), demonstrates the Atraumatic Hip Access Convenience Kit for hip joint access. These disposable kits contain everything needed for safe and streamlined joint access, including an atraumatic access needle, SafeCut™ capsulotomy blade, and FlushFit cannula.

Hip Joint Access Using the Atraumatic Hip Access Convenience Kit

Speaker  Hello, my name is John Reuter from Rothman Orthopaedics in Orlando, Florida. Today we'll be discussing safe hip access with the use of the Atraumatic Hip Access Disposable Kit. In this kit includes an Atraumatic access needle. This utilizes a spring loaded mechanism with a blunt tip that retraction protracts while penetrating the capsule, as well as a standard access needle. These come in 14 gauge and 17 gauge sizes. This kit also includes two 1.1mm nitinol wires, as well as the Flush Fit Cannula system, which comes in both standard and extended lengths. Also included in this kit is the curved SafeCut blade or alternatively, the CapsuleCut blade. Here we are obtaining hip access via a standard anterolateral portal with the use of Atraumatic needle. We can now see here. Once we are inside the joint with Atraumatic needle, that. The blunt tip is now protected again, with the goal of this to be minimizing any risk of iatrogenic injury once the wire is placed. When we come in with the FlushCut cannula system, the obturator and the cannula engage via this chin up bar type mechanism, which does have an indicator that says press to disengage these. The camera will then engage via a similar mechanism on the bridge, and we'll click into place. Once we have our Anterolateral portal established, we will create our Mid-anterior portal under direct visualization. Speaker  Again using the Atraumatic needle. When utilizing the trampoline technique with the pressure applied to the capsule can feel the blunt tip as it retracts and protracts again. And then once we pop through the capsule, we can see here that the inner stylet is protracted to minimize the risk of iatrogenic injury. Once we are happy with our needle placement here again we use the 1.1mm nitinol wire. Create a one centimetre longitudinal incision. Come back in with the FlushCut cannula system, the obturator and cannula. At this point we'll turn the water on. Once our mid-anterior portal is established, we'll switch the camera to the Mid-anterio portal. Now, looking back at our anterolateral portal, we'll proceed with our Interportal Capsulotomy with the use of the SafeCut blade. An additional benefit of the SafeCut blade is the blunt tip, which allows you to create a larger proximal leaflet, as there's less risk of damage to the femoral head. And with a larger proximal leaflet, we'll make subsequent capsular closure easier. Now coming in through our mini anterior portal with the SafeCut blade. To complete our Capsulotomy. Now that we have completed the Capsulotomy, the use of the arthroscopic shaver, we will debride pericapsular fat pericapsular soft tissue to make our capsular closure at the end of the case easier. Speaker  Once we have completed our capsulotomy and prepared our capsule, we'll proceed with placing a traction stitch in our proximal leaflet with the utilization of a proximal Anterolateral portal, which is approximately three centimetres proximal to our Anterolateral portal and 1 to 2cm anterior. We'll utilize the SutureCast for the placement of the stitch pulling the proximal leaflet of the capsule retracting it back. Proximally will aid in visualization for anchor placement and for labral repair. So with the traction stitch here, we can actually see the separation between the labrum and the capsule here. Here, placing a second capsular stitch in our proximal leaflet through a poke hole incision just anterior to our previously placed proximal anterolateral portal coming in through the capsule, approximately aids in capsular preservation. Now, with both traction stitches placed, we see here nicely a clear separation between capsular tissue and the labrum. Here we demonstrate a three anchor repair of the labrum with the use of the Knotless FiberTak. After we obtained hip access with the use of the Atraumatic hip Access kit, and then the use of proximal traction stitches through the proximal leaflet to obtain better visualization for anchor placement. With the use of these techniques, we minimize our risk of iatrogenic injury to the chondral surface or to the labrum.

Hip Joint Access Using the Atraumatic Hip Access Convenience Kit

Adam Anz, MD (Gulf Breeze, FL), overviews platelet-rich plasma preparation, details why platelet dosing matters and how to determine ideal patient dosing, and reviews relevant research about treatment applications for knee osteoarthritis.

Orthobiologics

Platelet-Rich Plasma Dosing

OrthoPedia:&nbsp;Platelet-Rich Plasma Dosing

This animation highlights the features and clinical applications of the ApolloRF® H50 probe, anatomically engineered for precision in the hip, with efficient tissue ablation and coagulation.

Imaging and Resection

ApolloRF® H50 Probe

ApolloRF® H50 Probe

This animation highlights the key steps for instrumenting bilateral pars fractures at L4 using Arthrex Fully Threaded Spine Compression Screws.

Percutaneous Pars Fracture Repair

Speaker  The ultra minimally invasive, endoscopic assisted percutaneous approach for pars fractures using Arthrex spine compression screws is indicated for adolescent and adult population. During this procedure, a spine specific endoscope may be used for visualization and direct access of the fracture site for preparation and biologic delivery. The Synergy imaging system, in conjunction with the ergonomic instruments, provides innovative new technology to treat this pathology. Localize using AP and lateral fluoroscopy based on pre-op imaging and CT. Mark a line along the inferior edge of the lamina of the level being treated. Mark midline under AP. Determine the screw trajectory and mark from the top of the pedicle to midline. Repeat on both sides for bilateral treatment using lateral fluoroscopy. Determine the screw trajectory and mark the skin. This will provide a reference for the AP entry point. Using AP and lateral fluoroscopy, Make a skin incision and insert the introducer needle. Docking on the inferior edge of the lamina. Remove the stylet and insert the guidewire through the cannula of the introducer needle. Use AP and lateral fluoroscopy to make fine adjustments to the entry point. Use a pin driver to advance the guidewire across the fracture, confirming the trajectory with AP and lateral fluoroscopy periodically during insertion. Widen the skin incision to accommodate the dilator and drill guide diameter. Speaker  Remove the introducer needle, then insert the dilator and drill guide over the guidewire, granting the bevel of the tip of the drill guide to best match the patient's anatomy. Remove the dilator and insert the drill bit over the guidewire. Position the drill bit coaxial with the guidewire and drill to the desired implant. Depth, confirming trajectory and depth with fluoroscopy periodically making sure to not advance the guidewire while drilling. Observe the drill depth via the laser line and the corresponding measurement on the drill guide to determine implant length. Reverse the drill bit under power 10 to 15mm. Stopping before the drill bit tip passes the fracture location. Remove the guide wire and insert a new guide wire. Continue to remove the drill bit using a ratcheting handle while maintaining the guide wire depth and location. Load the compression screw firmly under the screwdriver. Place the cannulated implant and screwdriver over the guide wire and advance to the desired depth. Periodically taking AP and lateral fluoroscopy to prevent advancement of the guide wire. The compression screw will be fully seated when the laser line on the screwdriver is flush with the back of the drill. Guide to confirm proper position. Remove the instruments. Close the incision and place a JumpStart bandage over the incision site.

Percutaneous Pars Fracture Repair

The BunionBrace™ surgical technique can be used to augment and reinforce a direct repair to the medial capsule during hallux valgus correction, with the goal of reducing the chances of recurrence of a valgus deformity at the MTP joint.

Foot and Ankle

BunionBrace™ Medial Capsule Repair

BunionBrace™ Medial Capsule Repair

Jonathan Riboh, MD (Charlotte, NC), demonstrates an all-epiphyseal, all-onlay MPFL reconstruction using Knee FiberTak® anchors.

All-Epiphyseal, All-Onlay MPFL Reconstruction Using Knee FiberTak® Anchors

My name is Jonathan Ribot. I'm here today from Charlotte, North Carolina, and I'm going to demonstrate for you guys an all online mpfl technique. So the instrumentation we need for this technique is shown here. We have a dedicated 2.6mm drill bit. It's really important to use this drill bit on the patella. The bone is hard enough that you do have to use a drill before putting in your anchors, and then on the femur to identify our location for the mpfl. We'll use a standard 2.4mm pin on the femoral side. My preference is to use this double knotless FiberTak anchor. It's a 2.6mm anchor, and it allows two knotless loops to fix the looped end of the graft on the femur. And then there's two different ways we can do this on the patella. One is with hybrid FiberTak anchor that has both a knotless pre looped, as well as a sliding suture that has needles already on it to reinforce that repair. The other option is to use the 2.6mm FiberTak button, and we'll demonstrate that in the in the cadaveric specimen. The final piece that we'll need is this 0.9mm SutureTape loop. This is nice. For a smaller graft, you might be using a gracilis in a smaller patient, and you don't want to have excess of suture load at the end of your graft. You want good collagen for healing. So this 0.9mm loop is really handy for that. So for an all online mpfl reconstruction, we'll use standard incisions. I like to mark out the 50 yard line of the patella and center my incision around the 50 yard line. You don't need to go any more proximal than the proximal pull of the patella. And here I've made this incision a little bit longer than I would in a real case, just for better visualization. On the medial epicondyle side, you can often palpate the adductor tubercle, which you see here in the medial epicondyle. As we know the graft will go right about here. In between those two I'm just going to make a slightly longer incision for ease of One important landmark I always want to identify is the muscular portion of the VMO, which you can see right here, mainly so that you stay out of it. It can cause significant weakness in the patient if you end up cutting into the fibers of the VMO as you make your exposure on the medial patella. So we always want to understand where that muscle is. And so one tip on the approach is as we know we want to be in between layers two and three, I actually don't expend much energy on trying to identify one. And two. It's really easy to identify three. So three is the capsule and it's got this yellow purple hue to it. It's very vascular. Whereas if layers one and two you can see our white and striated. So you can simply cut through the white tissue until you fall until this fatty yellow purple layer. And that's always going to be your interval right there. We've got the medial patella exposed here. And we want to roughen this bony surface in order to get a good healing surface for our graft. You see I've marked on the skin the 50 yard line, and that is a good landmark. Our first anchor is going to go in typically right at the equator of the patella. And it's important also to position this properly anterior to posterior. And so I have made a small capsulotomy here to show where the cartilage is. And you can see this is the cartilage right here. This is the anterior cortex up here we try to find ourselves halfway in between. If we get too close to the anterior cortex, we put ourselves at more risk of fracture. So for our second anchor, we're going to want to go halfway between the equator and the superior pole, which is about here. So if we have that distance, that typically puts us near the top of our exposure. As we prepare to drill into the patella, we have to remember that this is a very hard bone. And so we're going to always want to have an assistant give us counter pressure on the lateral aspect of the patella. That will really help stabilize that for us while we drill. So as we drill our patellar sockets to put in our anchors, we will use this knee specific drill guide. Once again, this is a pistol grip. It's very ergonomic and comfortable in your hand and has a shorter working length that's more convenient for open surgery. So the end of the drill, you see, has a crown tip that will engage nicely with the patellar bone and prevent it from sliding as you drill. So we're going to show two different ways of fixating the graft. The first option is going to be this hybrid 2.6mm that has both a pre pass loop for knotless fixation as well as some needles. And that's how we're going to recognize this anchor is that plastic sheath on the handle of the inserter that protects the needles. And that will allow us to reinforce our repair. You can also use those sutures additionally to repair your retinaculum down to the patella for a medial imbrication in addition to your mpfl reconstruction and as we drill into the patella. Given how hard the bone is, I'll typically cycle this 2 or 3 times to make sure we're removing any debris. You want to keep your guide hand nice and steady, and you see how easy this is to do with this shorter handle. We can slide our anchor into the inserter and then with good counter pressure on the patella we can tap this in. And what you'll see is you want to get all the way to the hard stop where your anchor abuts the drill sleeve. You can then remove the tab that releases the sutures. You can then remove the protected needles out the back of the guide and unwind those. Once your sutures are fully unwound, you can remove the inserter and remove the guide. So for setting the anchor we're going to want to grab these black sutures. These are the ones you can see that are attached to our needles. And these are going to allow us to set the anchor. So slow and steady retrograde pressure here will allow the anchor to deploy. And I'm applying maximum force here and getting no displacement of that anchor. If you could see that there was a small pop allowing that anchor to set. Knowing that we've got secure fixation. Another feature that you'll notice is that this is a SutureTape, and this is our first knotless anchor that has the SutureTape. So you have less likelihood of cheesewiring through your graft, particularly with the small gracilis graft. So this is going to help with fixation strength. So this is the second anchor option for the patella. And this is a 2.6mm FiberTak button. We can recognize it by these two loops at the top of the inserter. So with these anchors you always want to make sure you unwind the sutures before you pull the inserter back. So here you can see they're fully free. So for setting this button anchor, you're going to want to grab all four strands as one. And then again apply retrograde pressure until you feel the anchor deploy. It's very important on this all Onley technique that we get below the fascia as we try to put in our soft anchors. And so we do want to make a sharp incision into the fascia to allow us to get directly down to periosteum as we do our drilling. We can then place our self retainer deep to the fascia, and we'll be in the perfect position to do all of our work. This elevator is on the medial condyle, and you'll see that it falls into this recess, or this sulcus just proximal and posterior. And that is the exact location of the mpfl origin, the sulcus in between the medial epicondyle here, the adductor tubercle here. And once again, there's a sulcus right here. This can be confirmed fluoroscopic using the standard techniques. An important point here is that you have a choice in the trajectory of both your Pin and where you're going to put your anchor. Depending on your particular patient, a more traditional pathway is going to be to aim anteriorly and proximal. This will obviously keep you out of the joint. This can be a challenging angle in a younger patient if you want to avoid their faces. What you can simply do is raise your hand such that you are now aiming distal, as well as lowering your hand to aim anterior, and this will avoid the FICA, the notch and the joint surface. You just can't drill all the way across the femur in order to avoid overpenetration with your pin. In a younger patient, I like to mark the drill bit at 2cm or 20mm. That's been shown in cadaveric studies to be a safe distance where you're going to avoid injury to the trochlea, the notch or the phycis. So at this point, we'll advance our 2.4mm pin right up to the mark that we've made to avoid any over penetration on the femoral side, we're going to use the double knotless FiberTak shown here that has two pre passed knotless loops for fixing the femoral side of the graft. What I will do is I will slide the drill guide over my existing pin. Engage it here. And my assistant is going to provide counter pressure on the lateral knee holding the shaft of the guide to make sure it doesn't move at all. I can then easily remove my pin, and after we've inserted the anchor all the way to the hard stop, we can undo our black tab and unclip our sutures. I can then remove the inserter and remove my guide. So you'll notice here there is a white retaining suture that prevents me from accidentally shortening my loops. And I need to remove that. And to set this anchor I'll take a probe. You could use a switching stick or any similar device. Put it into the loop, and I can then use this to apply backwards pressure to set my anchor robustly. You don't want to pull on the tails, as pulling those tails will shorten your loop, and might leave you in a position where you can't pass your graft. My graft prep is actually very easy. There is none. All I do is I put an allis clamp on either end of the graft, and I mark the central portion of the graft as that is going to line up. You see here with our femoral anchor, to have the looped end of the graft on the femur. A nice option for passing the graft through the double loop is to have your Allis clamp already there. I can then hand off the graft to my assistant, who will pull it through very easily, and we will center that purple mark right inside the loop. I will then have an assistant hold the graft on either side so my hands are free. One thing I have learned in using this technique is if I pull down on my shortening sutures while the graft is engaged against the tapes, it will roll up the graft. And so I always ask my assistant to be one step ahead of me. And what I mean by that is they will have the graft 1 or 2mm away from the top of the loop, and as we progressively shorten it, they will follow me down so the graph does not end up rolled up. I will start here with the blue suture. And you can see as I shorten this, my assistant is constantly staying 1 or 2mm ahead of me. These SutureTape slide very easily down and as soon as I pull that all the way down, you can see just how robust and easy that fixation is. I have my second tensioning suture here, my black suture that can simply be pulled down in a similar fashion to augment the strength of our fixation and femoral fixation is completed at this point. If you grab the graft, you can see that it has robust fixation. Our two limbs are nicely fixed at this point. So I'm now going to shuttle the graft basically between these two. So I'm going to pass this clamp I'm going to get this clamp all the way through here. Do you see that. And I'm going to open it up. And we're basically going to pass the two limbs. At this point I can take a curved clamp and pass it between layers two and three, starting on the patellar side and ending at my epicondyle incision. I'll then sequentially pass my graft. I'll take the proximal limb first, and I can hand this off to myself and easily retrieve this on the patellar end. We'll then make sure to pull this clamp proximally, to make sure that we don't cross the limbs of our graft underneath the layers. You'll notice here that as I've passed my clamp a second time, I've made sure to stay distal to the first limb, and I can then hand off the second limb to myself. And that comes very easily. And we once again make sure to pull this more distally so that the graphs are not crossed. This is a final view of our femoral fixation construct. We can see an all onlay fixation here with our distal limb of our graft and the proximal limb of our graft, with a nice layer in between those. So they are taking separate trajectories both underneath the fascia which is this layer right here. So now we are ready to fix the graft on the patella. Typically for this, I'd have the knee in resting on a bump around 45 degrees of flexion, and I simply leave the patella where it wants to be in the trochlea. In that sense, I'm using the mpfl simply as a check rein. I'm not trying to pull the patella over medially, which will avoid issues of over constraint. As I lay this graft down, I can mark exactly where that graft is going to meet the suture anchor on the patella. And that will be my guideline. So once again, if I lay this graph down right here at that layer, it will be in perfect tension and not over constrained with this hybrid anchor. I can have my assistant place a clamp through the repair loop, and I can hand off the graft to the assistant. And now I will use the blue pulling Strand to shorten this limb. If there's any concern about the graft slipping through the knotless loop. We do have these nice black sutures that are suture tapes preloaded with the needle, and I can use those to reinforce my repair. At this point, we have a couple of options. We could use our FiberWire scissor to simply cut these tails. Additionally, we could leave these intact with the needles on them if we wanted to use these to augment our retinacular closure. What we can cut at this stage is the blue suture that has tightened down on the graft. And that's option one for patellar fixation. At this point, we can cut off the excess graft typically sharply. You want to leave about 8 to 10mm of space here. If you cut too close to your sutures, if there's any slippage of your knot, it could cut right through the graft. And so I'll typically leave about a centimeter of tissue. And that's some added collagen for healing. So the second option for fixation on the patella is patella is to use this button construct in a very similar fashion. With the knee around 45 degrees, I will simply lay down the graft and I will mark exactly where it wants to overlie the anchor. This is particularly important in this technique, so we can see how that will sit perfectly over our anchor. We'll now use the 0.9mm FiberLoop to whipstitch our graft. And we'll simply stop exactly at our purple mark so we get the perfect tension. So at this stage, you can see I've come all the way to my purple mark and I'll do a locking pass by backtracking a millimeter or so, passing the needle there so there's no slippage. I can then cut off the needle from my FiberLoop, and we're ready to load this into the anchor. So if you see I have two free ends, and at the anchor level I have two passing mechanisms, one here, one here, that will allow us to pass each of those limbs. So you'll want to pass about 3 to 4in of suture and cinch it down. And then you can pull this through the anchor. We'll then do the same thing with our other end. We'll get ourselves all lined up. So we'll have our graft sitting in the appropriate position. And we can reciprocally tension each of these sutures until the graft is firmly seated against the anchor. Tie these two sutures to each other with the simple surgeon's knot. We can cut our tails. And just like on our first anchor, you do see that we have some excess length that can be removed. And that completes our all onlay mpfl reconstruction. At this point, we can either use free sutures or our existing sutures with needles from our hybrid anchor to repair the retinacular tissue such that they are brought over top of the graft, essentially making the graft to disappear. It's nice to do somewhat of an imbrication of this layer to reinforce that medial reconstruction. So if this was the original tension of those medial tissues, I can simply advance them by 8 to 10mm with my repair to reinforce my reconstruction. At this point, there's two options for closing the retinacular layers. You can either use a free suture, or you can use the sutures that are integrated into your patellar anchor. And I'll demonstrate both of those for you. If we're going to use a free suture, it's helpful to use this new double armed SutureTape that will allow us to do a pance over vast imbrication of that retinaculum very easily. It will be important to incorporate both layers one and layers two in our closure. So here I've grabbed both of them. It's also important to take a bite relatively distant from the free edge. The farther my bite is from the edge, the more imbrication we will attain. So my first bite will go through layers one and two, and with that same suture. I will then capture the periosteum on the anterior patella. This is typically robust tissue that holds suture very nicely. I can then grab the other suture end and create a mattress type construct. Again incorporating both layers one and two. And for our final bite taking a healthy portion of this patellar periosteum. You can see as I tension these sutures, how that will pucker up the medial tissues and advance them onto the patella. I can then simply tie these two suture limbs to each other. Creating a nice imbricated medial retinaculum. It is then easy if you choose to take an absorbable suture and run this more superficial layer. Closed. To fully complete that. Imbrication incorporated suture tapes with needles that came from our hybrid FiberTak anchor. What's important to remember here is that these are not sitting at the anterior edge of the patella, but rather at the midpoint of the patella. So if I put these stitches right through the free edge, I will actually be under tensioning the medial layer. And so just like on our first bite, we want to come quite far with our needle pass to make sure that we get appropriate imbrication of the tissues. The amount of imbrication again is directly correlated to this distance shown here. We can complete our second mattress stitch adjacent to our first. Remove the needles for safety of time. And at this point tie our medial retinaculum down to the patella. You'll notice that with these two different techniques. The knots end up at different locations. If you use the hybrid anchor, your knot ends up down here. If you use a free suture, you're not will end up on the patellar side. I do encourage you at this point to use just an absorbable suture to close this final layer to avoid any egress of joint fluid. The final step at the epicondyle side is to take our fascia that we've previously incised, and simply bring that over top of the graft. Once again making that graft sub fascial closure of this fascia can be done with any suture of your choice at that point. That completes the all on Mpfl reconstruction after standard skin closure. Before closing the fascia, it will be important to cut the excess suture length from your double knotless FiberTak and then simple skin closure is performed on both incisions.

ASC X

Sports Medicine

Arthroplasty

Extremities

Trauma

Biologics

Spine

Cardiothoracic

Endoscopy

Imaging and Resection

Fluid Management

Aesthetics

What's NewOCT 26

Tensionable Knotless Remplissage Technique Using the Knotless FiberTak® Remplissage Implant System

What’s New This Week and Prior

OCT 25

Arthrex Rotator Cuff Express Instrument System

OCT 24

OrthoPedia: Tibial Plateau Fractures: General Surgical Considerations

OCT 23

Osteochondral Lesion Treatment With the 20 mm Precut OATS® Kit

OCT 22

Percutaneous Pars Fracture Fixation