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.

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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

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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.

Knee

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.

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

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.

Shoulder

Arthrex Rotator Cuff Express Instrument System

Arthrex Rotator Cuff Express Instrument System

Erik Kubiak, MD (Las Vegas, NV), demonstrates using the QuickPass™ FiberTape® cerclage system to achieve reduction of an oblique fracture of the distal femur. He provides an overview of the unique instrumentation that allows for a faster, more efficient technique to pass FiberTape cerclage around bone. The FiberTape cerclage with QuickPass tube is used in conjunction with the cannulated, slotted QuickPass passers to place the FiberTape cerclage around the fracture twice without the need for a separate shuttle suture.

Long-Bone Fracture Management Using the QuickPass™ FiberTape® Cerclage System

Speaker  Eric Kubiak from Las Vegas, Nevada, demonstrating the Fibertape cerclage with quick pass tube. Before you. We have the Fibertape cerclage with quick pass tube. The three straight passes medium large and the exaggerated curve passer. The advantage of the Fibertape cerclage with the quick pass tube is that it really facilitates the two passes of the Fibertape Cerclage, much like with the similar ease to the single pass of a of a steel cable. Without all the disadvantages of the steel cable you can see demonstrated here the channel in the passer. And now we'll take the quick pass tube. And slide it through the channel. Retrieve. You can see the tape clears and then you can pass second loop. And now you have the two passes without having to use the Fiberlink. Extensile direct lateral approach to the distal femur in the setting of a modeled long oblique fracture of the distal femur. This is a typical place where one might employ cerclage for provisional reduction and stabilization prior to definitive fixation with either plate or retrograde intramedullary nail. We find this often in the setting of periprosthetic injuries, particularly proximate to a distal total knee or distal to a proximal femoral implant. Now we will demonstrate passage of the passer once a cable passer has been deployed. So now with the passer around the femur we'll take the quick pass tube pass it through. It's my preference to use the near side of the pass on the handle side. I think it's a little bit easier than passing. Speaker  Oftentimes, the leading end of the tube has some muscle or little bits of tissue in it, and the near side is cleaner. With that, you've got two wraps around the femur and the tube can be recovered. Take the end, pass it through the nitinol loop. Not too much of a loop. You don't want the doubled stranded component of the Fibertape cerclage to really, at this point, you don't want it engaged because it'll make it a little bit. Recovery of that difficult. That's through close. Begin to close the hitch. You can already see the fracture is beginning to be reduced. With the disposable tensioner. You really want to make sure. Oftentimes it'll you'll have used it before, and some of the excursion of the tensioner will be consumed. Just make sure that you back it off, have reversed it all the way before you go to tension. That gives you the maximum amount of excursion. Make life quite a bit easier. I'll pass a double strand through. Lock on the cleat, tighten to. At a minimum of three. I like somewhere between 3 and 4 bars. Back it off all the way. I'll back it off. Slide it forward. Take one strand. Separate cut. I don't disengage it from the holder. Makes life quite a bit easier. Then pass a half hitch. Slide it. Secure the one side Through the loop. The open end two passes around and then two passes through the cleat. Speaker  Retention to 3 or 4. I like four. We're good. You can back this off. And pass another half hitch. You don't even have to back the sleeve up past the half hitch. Over. Reload it. Leave about a five millimeter cuff. There you go. The nice thing about this compared to cable is you don't have this. This cuff isn't going to lacerate tissue. It's not going to potentially inadvertently injure an artery. You're never going to get an arterial laceration with this soft uhmwpe material on a long spiral like this. I typically use two cerclages for stabilization before placement of a nail or plate. So we're going to demonstrate the second here. We've gone to the larger parser to facilitate getting around the distal flare of the femur. Again using the quick pass tube. One pass. Easy. Second pass get false free of the tube. What we have before us is the Pre-reduction image and the post-reduction image after application of Fibertape Cerclage, you can see the broad displacement. You can see how the Cerclage has done a fairly adequate job of reducing the fracture. We're still probably a millimeter and a half long, but that's going to go away with the final implant, either the nail or the plate. But overall, a quality reduction, at least as good as that I can achieve with a clamp. But unlike a clamp, I can leave it behind and basically maintain the reduction through the whole surgical process.

Long-Bone Fracture Management Using the QuickPass™ FiberTape® Cerclage System

This video discusses the decision-making process and surgical management options for the treatment of peripheral nerve injuries.

Hand and Wrist

Peripheral Nerve Injuries: General Surgical Considerations

OrthoPedia: Peripheral Nerve Injuries: General Surgical Considerations

Peter J. Millett, MD (Vail, CO), uses the Knotless 1.8 FiberTak® implant system in a cadaveric demonstration of a knotless Bankart repair. Dr. Millett reviews a range of tips and pearls from portal placement to sequential repair tensioning. Tensionable Knotless FiberTak implants of varying colors provide multiple points of fixation to restore anatomic tension to the glenohumeral soft tissue.

Tensionable Knotless Bankart Repair Using the Knotless 1.8 FiberTak® Implant System

Hello, I'm Peter Millett from Vail, Colorado. Today we're going to demonstrate an arthroscopic bankart repair using the 1.8mm Knotless fiber implant system. So we've established our posterior portal, and I'm going to demonstrate the new five millimeter percutaneous cannula. I'll put a spinal needle in first. And then this can be placed over a guidewire. So it allows you to place the anchors wherever you want. So this will be a high one here. At this point I'll have my assistant just hold the scope. We'll pull out the center portion of the needle, feed the little wire down. We'll just make a little nick in the skin. Here for about 4 to 5mm is usually sufficient. And then this cannula can just go right over it. And you can place this anywhere, anywhere you need. And the nice thing is that the 1.8 anchors will fit through that. Great. So that's our first portal there. So now we've established our second portal here. This is an 8.25mm cannula. I like to put it just over the subscapularis. Usually you can reach most of the glenoid with with this approach. Occasionally, if you need a really low anchor, you can go in percutaneously using this five millimetres cannula with the same technique. But in this case, I think we'll be okay with these two two cannulas. The more medial this is, the easier it is to pass it around the tissue. The more lateral it is, the easier it is to insert your anchor. So you have to kind of take that into consideration. Then what we'll do is we'll mobilize all the labrum and the capsule here, which we've done. My assistant just kind of pull back on the arm a little bit. And that helps to visualize that. Sometimes we use a 70 degree scope or this scope viewing from the back, just to help us see this as well. You want to have it mobilized until basically you can until you can see the subscapularis fibers underneath it. Now we're going to demonstrate putting our first anchor. And this is the curved guide for the 1.8mm anchor. We'll place it in through our lower cannula here. If you put the obturator in, it just helps to decrease any fluid extravasation. And then once it's in position, ideally we'll get it up on the glenoid face. And then I'll tap it with a mallet just to secure it on the glenoid here. And then we'll come in with the flexible drill. And then usually this is this phone's kind of soft, but in a young patient, I would cycle the drill 3 to 4 times to make sure you clear all the bone debris out of it. Now, we'll come in with our with our anchor. This is the 1.8mm knotless fiber tack anchor. And there's a little recess in the in the drill guide here. And it's important to line the little handle here up with that so that it slides down properly. And then we'll insert it by hand for a few millimeters and then finish it off by tapping it in place. And this just bottoms out on the inserter. I'd like to just check the prongs, make sure they're intact, and then we'll remove the inserter at that point, and then we can pull back on the anchor and make sure that it seats properly. So now our anchor is inserted. You'll see that there's three sutures in this 1.8mm knotless fiber tack anchor. The repair suture in this case is blue. They come in different colors in this system to help with differentiating suture management. But you want to retrieve the repair suture out through the superior cannula, and then you'll leave the shuttling suture here in place out through the inferior cannula. And try not to touch these sutures very much so that they don't get extra twists in them or get damaged at all. At this point, we'll then come in with a lasso. This is a 25 degree left curved. So what I do is oftentimes I'll just kind of stabilize the tissue with the grasper. And then I'll come in perpendicular to the capsule and pop through and then rotate my hand around until I see it in the defect there, and then retrieve the. Retrieve the wire out through the superior cannula. Then at this point, we'll just shuttle this repair suture back through around the capsule and labrum, and you untwist this. Then we'll just retrieve that repair suture out through the capsule and labrum. And again we try not to twist these at all. So there that's out. Now one thing I do is I just kind of milk the suture a little bit to take any longitudinal twists out of it. And then I'll put this park this over to one side, and at the same time I'll take the shuttling suture here, separate that. I always separate it from the cannula out. So I'm not putting twists into it and then move it back and forth. Some people call it a floss technique, and then we'll take an extra suture. At this point this is a counter-traction suture. Shorten the loop here and then we'll we'll pass our repair suture through through the loop and then fold it. There's a little mark purple mark right there. Fold it to that point. Now I'm just going to convert the suture. So I'll just do this kind of start off slowly. Make sure the suture is entering the cannula properly. And then just pull it out. That converts it. Grab the end of the repair suture. And then at this point now I can pull back on this traction suture. It puts tension into the loop and it makes it go in nice and smoothly and without any twisting. And you can see that I'm going to back up here so we can see that being delivered into the joint here. So there you can see it. It's getting get it pretty close. So just before we tighten it up finally what I can do is I can come in with my grasper again and just grasp the soft tissue and pull it up and reduce it like that. Pull it tight. You see, you still have this traction suture here. We can remove that at this point. And we can use that again. Use it over and over again for the next ones. And then we'll just do our final tightening here. And we've got a nice shift and we've got a nice restoration of the capsule labral junction and nice bumper in the front of the shoulder. So at this point you have the option to either cut the suture or you can leave it and then do sequential tensioning. I think if you're going to do sequential tensioning sometimes taking this out of the cannula can be helpful. So you don't get tangled on the other sutures. So just put a switching stick in, pull the cannula out and then we can grab the suture. And then we can put the cannula back in. And now we have our suture kind of out of harm's way. And we can put our next anchor in without without worrying about getting tangled or twisted. Great. So we've got our first anchor in. Now we're going to place our second anchor. This one's a little bit easier. Usually the lowest one's typically the most challenging. Typically we'll place it about the first one around 5:00, then 4:00 and 3:00 or so. Place the guide in place. Tap it up on the face of the glenoid. Secure it and we'll come in with our flexible drill. And then it's important to pull the drill back beyond that little opening in the. In the insertion sheath so the bone debris can be removed from the. From the tunnel. And at this point then we're going to come in with our second 1.8mm knotless fiber tech. This one has a different color repair suture. So we'll be able to distinguish those again. You'll line up this with the the recess part of the inserter here so that it goes around the curve properly and then insert it by hand initially for the first few millimeters to get it started, and then tap it in place. Remove the grommet. Tap it to disengage it. I'll come in with my retriever. This is a mini kingfisher retriever. And again you have your repair suture and then you have your shuttling suture. So the repair suture in this case is is white and light blue. So we'll retrieve that separately out of the superior cannula. And again now we'll come in with my 25 degree left curved lasso I hold the these sutures tight so I don't damage them at all while I'm inserting this. And I'll just back this wire up. And at this point I can grab this tissue, kind of pull up on it a little bit so it has good tension. And again, go perpendicular to the capsule and come around, hit the glenoid, and then we'll pop through just below our anchor and then retrieve the retrieve the wire out the superior cannula. And then we'll shuttle our repair suture back down through through the cannula and then around the capsule and labrum. Okay. So at this point again we'll we'll separate these sutures so that it's so that they don't get twisted. Just put the repair suture to one side and the shuttling suture to the other side. Strip this a little bit to make sure there's no longitudinal twists in it. Now we'll come in with that counter-traction suture. So this goes between goes between those two sutures, between the repair suture and the shuttling suture. Now we'll just convert the anchor. So again you fold it over. There's a little blue mark right there that's appropriate. And then at this point we'll convert it. And now we have this this traction suture. Again it makes it a lot smoother a lot less chance that you're going to get tangled or twisted. And it really just makes the procedure a lot, a lot simpler. So at this point we have our suture almost fully tensioned. I'll come in again and grab the soft tissue, and I can get it right to where I want it to be. And then at this point, I then can remove that traction suture, and then we can get the final tension on our repair stitch here, and we can retension our first one if we want. And so you can get a little bit more tension out of that. So now we've completed putting all our anchors in. This is our lowest one here, our middle one, our second middle one and our top one. We put four anchors in this repair. I usually use four. Sometimes if it's a really big tear, even five, you can see how it's restored the capsule labral tissue here. Now what we'll do is retrieve our repair sutures so that we can go ahead and tension them again. We'll pull them all out through the cannula, and then after that, after we tension them, we'll we'll then go ahead and and cut each suture. So we'll just start at the bottom here you can see we can retension that a little bit. We looked at this in the lab recently and showed that you get about an extra millimeter or so when you do this. Because as you can imagine, as you pull each suture up and put each anchor in, it helps to spread the force over the whole construct. So there we've tensioned each one individually. So now they're all tight. So at this point we'll then we'll just cut each one sequentially. Just a little pearl. When you're using the cutter it's always important to cut it right in the center. You don't want to cut it off to the side like that. You'll get frayed edges. So cut it right in the center. Here's our our final repair for anchors for bankart repair. This is with the 1.8 Knotless. Fiber tech gives a very nice low profile repair. You get multiple points of fixation, minimal bone resection, very strong. You can retention it at the end as well, which I think is a nice advantage. Hope this helps you in the care of your patients. Thanks a lot.

Tensionable Knotless Bankart Repair Using the Knotless 1.8 FiberTak® Implant System

Seth L. Sherman, MD (Redwood City, CA), demonstrates a reconstruction of the medial patellofemoral ligament (MPFL) using a RT TightRope® SB implant and Hybrid Knee FiberTak® anchors.

MPFL Reconstruction With the RT TightRope® SB Implant

MPFL Reconstruction With the RT TightRope® SB Implant

Patrick J. Denard, MD (Medford, OR), presents findings from two retrospective studies evaluating patient outcomes after subscapularis repair. The first study highlights the importance of subscapularis healing in both isolated and combined rotator cuff tears, showing improved patient-reported outcomes and return to activity when healing is achieved. The second study compares soft-body anchors to hard-body anchors, demonstrating similar functional outcomes with a trend toward improved tendon integrity using soft anchors, such as the FiberTak® anchor.
<a href="https://www.arthrex.com/resources/VID1-007954-en-US/subscapularis-tears-presentation-series-part-1-recognition?objectID=human.resource.en.1408c35c-14c4-4e38-bd2c-52b4527fe5e6.1&amp;queryID=c8a8fd6a7aad425f4c7a7ddea15222ab">View Part 1: Recognition</a>
<a href="https://www.arthrex.com/resources/VID1-008214-en-US/subscapularis-tears-presentation-series-part-3-predictive-healing-index?objectID=human.resource.en.b73b476b-cb6f-4a31-ba76-c04946ffe866.1&amp;queryID=b21ef7671e7ec60860e20c3c75d6ab8a">View Part 3: Predictive Healing Index</a>

Subscapularis Tears Presentation Series (Part 2): Outcomes

Speaker  I'm Patrick Denard from Medford, Oregon. I want to share with you two recent articles we've published on the outcomes of Subscapularis teres. This first study looked at the outcomes of patients undergoing isolated compared to combined subscapularis repair. Meaning looking at isolated subscapularis teres compared to those who also had associated supraspinatus or even three tendon tears. So we had a series of over 500 patients, 279 of which had post-operative ultrasounds we could use to assess healing. And we had a mixed cohort in which we had some isolated tears, some combined into anterior superior and some three tendon tears. What you'll note here is that overall healing of subscapularis, fortunately, is very high. It's over 80% of those who have subscapularis tear heal, regardless of associated tears and patient reported outcomes across the board are very good when there's a subscapularis tear. You can see we have improvements across the board. There was a trend toward higher ases scores for patients with isolated or two tendon tears, compared to those with three tendon tears. I think what's really notable about this study, however, is that it shows that subscapularis healing matters in those patients who did not heal, regardless of whether or not there was associated tears. Outcome was decreased. So in this table, you can see that SV scores are subjective. Shoulder values were higher when the subscapularis healed. Now that intuitively makes sense. But I think this is important because what it tells you is that we're looking at just the subscapularis. And even in the setting of a three tendon tear, if you can get subscapularis healing, you're likely to have a good outcome. Speaker  So that was not only in terms of patient reported outcomes, but also in return to activity and satisfaction among these patients. So the take homes here really are that subscapularis healing is high regardless of associated tears and subscapularis healing impacts outcomes. And so what I take this to mean is it really highlights the importance of identifying the subscapularis and getting a very good repair in your patients to ensure they're going to get the best outcome possible. This next study, we compared the performance or healing of hard body anchors compared to soft body anchors. So I had a retrospective study using fiber tacks, and we did a 2 to 1 match control series compared to a series of hard body anchors, because my practice transitioned from using primarily hard body anchors to using soft anchors over time. This is a two year minimum follow up study. You can see, according to patient reported outcome measures, both groups do very well. So regardless of using hard body anchor or soft body anchor, you're going to have good functional outcomes. Healing, if you look at this was overall similar, but there was a slight higher number of patients who had type one healing, meaning a normal tendon with the use of soft anchors that may have to do with less violation of the footprint, which is one of the reasons why I really prefer soft anchors medially as much as possible. Speaker  So this is an example of my typical surgical technique that I use to repair the subscapularis. Here we have a high grade partial tear in the left shoulder. I'll insert a guide through a percutaneous anterior portal. And through this guide, I'm going to place a two six fiber tack anchor. I like these two six anchors because they are self punching feature, which really helps improve the speed of my procedure, but also, importantly, minimal violation of the footprint. I can then retrieve the repair limb out the anterior superolateral portal. I'll pass that repair limb through the subscapularis with a scorpion, and then I simply just need to convert by retrieving the shuttling limb out the same portal. I can then, on the exterior, pass it, repair limb through the loop, and bring the repair limb down into the body of the anchor to get a low profile Knotless repair. The closed knot cutter is also a nice trick to provide counterforce as I'm applying my final tensioning. I can then cut that limb short and have a low profile repair of my subscapularis with minimal violation of the footprint using the Knotless fiber tack anchor. So take homes here. That patient reported outcomes are similar whether you use soft or hard body anchors in subscapularis repair, there might be a slightly higher trend toward normal tendons in healing when you look at that, according to Sugaya classification. And I really prefer based on that, using soft anchors as much as possible in my patients. Thank you.

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