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At the Orthopedic Technology and Innovation Forum, Paul Brady, MD (Knoxville, TN), discusses key diagnostic and surgical principles for managing subscapularis tears and associated biceps pathology, emphasizing improved visualization techniques, knotless anchor repair methods, and strategies to optimize healing.

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Managing the Subscapularis and Biceps Tendon

OrthoPedia: Managing the Subscapularis and Biceps Tendon

Rachel M. Frank, MD (Denver, CO), demonstrates the Synergy Power™ system.

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Synergy Power™ System Product Demonstration

I'm Doctor Rachel Frank, a sports medicine and shoulder surgeon from the University of Colorado, and I would like to provide an overview of the Synergy Power system. This system was designed and developed in-house by Arthrex Product Development engineers, and is assembled at the manufacturing facility in South Carolina. I'm excited to walk you through the system and my favorite features of Synergy Power. The Synergy Power system is a medium and large bone system comprised of two handpieces, a dual trigger rotary drill, and a dedicated sagittal saw. These two handpieces are designed to cover a wide range of orthopedic applications, including sports arthroplasty and trauma procedures. Both Handpieces are ergonomic, lightweight, and durable, making them easy to use and comfortable for all hand sizes, even during long and complex cases. My favorite feature of the drill is the twist collet mechanism. This design is intuitive and allows for attachments to be quickly changed during a case. This feature saves time in the O.R., which increases our efficiency and creates a smoother experience not only for me as the surgeon, but also for the staff. Synergy power includes a comprehensive attachments portfolio for all drilling, reaming, sawing, and burring needs. The system will offer keyed and hybrid drill chucks and three different sized wire and pin drivers for optimal wire or pin retention. With the three different sizes clearly labeled S, M, and L, one features that you no longer have to adjust the attachment to accommodate your pin. So for example, here we have the medium attachment for the wire. Pin driver easily pops in and you can see that this tells you exactly what size that you're able to use in terms of your K wires. And for example, we'll place a two for k wire into the attachment. And that's all you need to do. And if I move around or the scrub nurse or scrub techs handing me the drill, I don't have to worry about the pin falling out, getting lost on the floor and having to scramble for another pin or another wire. We'll take the pin out when we're done and say we want to. Now put in a smaller pen, simply use the twist mechanism. And now we're going to use the smaller attachment. And we can see it's clearly labeled with an S. Easy to pop in. And we'll take a smaller wire in this case. And again as long as it's within the size that this particular attachment allows which is very clearly labeled, you no longer have to worry about where your pins or where your wires are going. And this makes it so much easier for both you and whoever's handing you the instruments. There are also two attachments micro, sagittal and reciprocating for making smaller cuts. Various other attachments along with several attachments, including a Hudson modified Trinkle reamer. The drill and ream functionalities are built into the attachments, so I don't have to switch between drill and ream modes during a case, and in general, I don't have to use as many handpieces when operating. Synergy power is all about providing greater ease of use, flexibility and ultimately cost savings. Now moving on to the sagittal saw. This handpiece is intended to be used for heavy duty cutting, and my favorite feature is the open hub design. No more blind insertion, as this design allows for easy visualization and confirmation of blade placement. As you can see here. Take the blade, push the button, insert it and done. Very easy. You can see exactly what you're looking at, and you don't have to guess that the blade is fixed. In addition, this ensures that the area has been properly cleaned after undergoing sterilization because you can see into every nook and cranny quite easily. The SOC features an indexing head that rotates every 45 degrees. Offering eight different cutting positions, and comes with a wide variety of large sagittal blades to meet all sawing needs and preferences. Next, let's discuss the Synergy Power battery packs and charger. The battery packs are sterilizable and offered in both a small and large size. Small for light duty procedures and large for heavy duty procedures. The charger has a simple user interface to easily determine the state of charge and offers fast charging. Charging a small battery pack in up to 30 minutes, and charging a large battery pack in about 120 minutes. One of the most unique features of Synergy Power is that this is a modular system with two handpieces. It has everything you need, but takes up so much less space than you're used to. That's better for your surgery center, better for speed, better for your entire team. This system is going to save money and be more efficient, which is going to make you as the surgeon and your team at the surgical center much more happy and ideally provide cost savings to the entire system. Finally, Synergy Power, of course, fits in nicely with Arthrex synergy family of products. Overall, Synergy Power is a powerful, versatile, and reliable powered instrument system, and I encourage you to experience synergy power as soon as possible.

Synergy Power™ System Product Demonstration

This animation demonstrates unicondylar knee resurfacing using the iBalance® UKA system, which helps improve operative efficiency due to the expanded flexibility provided by the new adjustable spacer block.

iBalance® UKA Technique

iBalance® UKA Technique

Marc W. Gerdisch, MD (Indianapolis, IN), demonstrates his preferred thoracotomy closure technique with FiberTape® sternal closure using a dual-tensioner approach. He highlights the advantages of FiberTape Cerclage, noting its broad footprint helps reduce the risk of bone cut-through compared to traditional suture, while the enhanced closure method minimizes the potential for lung herniation.

FiberTape® Sternal Closure for Rib Approximation After Thoracotomy Incisions

I'm Mark Curtis. I'm chief of cardiothoracic surgery at Franciscan Health in Indianapolis. We're going to show you our method for using the fiber tapes for Rib approximation in any size thoracic incision. So for anyone who does thoracotomy surgery, whether that be lung surgery or minimally invasive valve surgery, no matter what size incision you make, if you make an incision in the intercostal space and you spread the ribs even a little bit, you are then vulnerable to lung herniation. So for folks who have been doing thoracotomy surgery of any variety for a long time, they've encountered a lung herniation at some point. So what we've been doing now is using the fiber tapes for our rib approximation for any thoracotomy. We do that as a figure of eight. We use the blunt tip needle, and we always start at the middle and work our way out. So in this case I'm going to use two figure of eights. And the first one will go here below this rib. And then the second is going to go a little bit farther medial. And we can really travel. We can cover the whole space of the incision. So one of the things that you'll notice of course, about the fiber tapes is they're considerably wider than the heavy suture that we would typically use. And that gives us a couple of things. It gives us the power to approximate those ribs as much as we choose. We don't want it too tight, but we want to bring them together. And then also because they're wider, they're much less likely to cut through the rib when you tighten them down. So we have the ability to be a little bit more vigorous with the tension on the closure than we would with suture, because it won't cut through or it's less likely to cut through. And also you're going to see that it's a titratable amount of tension so that we can really decide just how tight we want it and how close we want the ribs when we finish. So now we're finishing our figure of eight. We're going to come around. We started in the middle, worked our way out medially and again. This could be for any size incision. Then our final bite takes us back laterally to where we started. So take another tape and then again starting toward the center of the incision. We'll pack our first pass. Next bite is going to go way lateral out toward the end of the incision. Another lateral bite. And then we're going to finish in the middle again. So now we've got our fiber tapes in position. And we're going to go ahead and start to pass them through. So we can take all our retractors out. So we've passed the tail of the fiber tape through the little cinch knot that's built into it. And Then if we just want to take some of the slack out, we pull up on the one that's farther medial, the farther past that we did earlier of the same suture we pull up on that, we go back and forth a little bit and we get them close together. And again, same thing. Pull up here a little bit. We'll grab this side. We're work that down a little bit now. So now you can decide how you want to approximate this. We can do this by hand just by doing this. And the ribs have come together quite a bit already. So again here push that down. Pull this back so it can be done most of the time completely to close that way if you want to. But you can also go ahead and use the Titratable tensioner so that you can set the amount of tension that you're going to have on the sutures as you approximate the ribs. And I think this is the ideal way to do it, really, because it is more powerful if you tighten it all the way. So you have to be cautious Yeah, but it also is something you can do in small changes. So I tighten this a little bit. So the tensioner allows us to kind of titrate the amount of force that we're putting on there. We can feel the space between the ribs. We don't want the ribs right together because we don't want them to rub against each other. That can actually cause pain for the patient. And then you can have your assistant hold this one and then take the second tensioner. The fibertape is passed up from the tip of the tensioner. We aren't separating the tapes. There are two strands. The two strands go all the way up through the wheelhouse here. And then as I turn the handle, the wheelhouse turns and it closes the space. So now I can feel in there. I've got just about a finger breadth of separation there, and we're going to stop there. So and the different surgeons will want this, you know, different approximated differently with greater tension. But this is fine for us. We've got it nicely closed there, and then we release the tensioner and then we cut these strands. And we tie on top of our slipknot. So there's a slipknot that's built into it that's already there, that holds. So it's not moving. And then just in order to secure it, I'll put three knots on top of that and then we'll cut this one. So here I can feel and I have my gap here that I think is reasonable, which is just barely maybe the height of my, my index finger. And so the ribs aren't rubbing together, but there's also not a gap there that would pose a problem later. We put three knots on top of that and we cut both of those. And then that's our closure for the inner space.

FiberTape® Sternal Closure for Rib Approximation After Thoracotomy Incisions

Elizabeth G. Matzkin, MD (Boston, MA), demonstrates an ACL reconstruction using a GraftLink® construct with RT TightRope® SB implant with FiberTape® suture for the InternalBrace™ technique.
The InternalBrace surgical technique is intended only to augment the primary repair/reconstruction by expanding the area of tissue approximation during the healing period and is not intended as a replacement for the native ligament. The InternalBrace technique is for use during soft tissue-to-bone fixation procedures and is not cleared for bone-to-bone fixation.

GraftLink® ACL Reconstruction Using the TightRope® SB Implant for the InternalBrace™ Technique

Hello, I'm Elizabeth Matzkin from Boston, Massachusetts, and today we will be demonstrating an ACL graft reconstruction with internal brace technique and the new tightrope SB. As you can see here, we have our graft out on the table on our Graph Pro ready to go. We have a hamstring semitendinosus that's been quadrupled using a standard grafting technique. And we have our new tightrope SB on both sides of the graft you can see the yellow suture which is the soft button. This is just like our tightropes we've been using for the last ten years, but there's no metal. So for patients that may have metal adversity or a metal allergy, this is going to be perfect. There's also some other advantages to using the soft button, which you will see in our demonstration on our tightrope SB. You can see our blue passing sutures, our white tensioning sutures, our internal brace sutures, and these sutures which are used for elongating, which you will see as we pass the button into the knee for our ACL reconstruction. On the tibial side of our graft, we can see our blue passing sutures. These suture tapes here in the middle are from our graft prep. So there are saved sutures. We can see our white tensioning sutures. And then again, we can see the suture that we're going to use for elongating the suture button when we pass it into the knee. So we have about a 30 millimeter femoral tunnel. So we've marked 30mm from the end of this soft button. I also like to mark my graft around 15 to 20mm. It's often where we have these sutures wrapped around the graft itself. But that will help us as we pull the graft into our tunnel. And we'll mark it also on our tibial side. So here we are. We're in our right knee. We've already prepped our femoral and tibial tunnels. We have sutures passed through them so we can get ready to pass our graph with the new tightrope SB. So we're going to pass this through our suture here on the outside. And then we're going to shuttle our white tensioning sutures and our blue passing sutures through the knee here. As you're doing this, you're going to have one hand pulling through the sutures through the femoral tunnel and your other hand holding on to the the graft. And the extra suture in order to feel the tension as the graft is passing, as we're getting ready to pass our tightrope, SB, we have one hand holding our tensioning and passing sutures and our other hand holding the trailing sutures. This allows us to keep the tightrope sb lengthened as we pass this through. We've also switched our scope to the 70 degree so we can watch this go up our femoral tunnel. So again we're holding both ends of the tightrope. We're watching it up the tunnel. We can see it just passed through and we could feel it flip right there. And the other thing we can look at is we can see our mark that we made. On the sutures, which is also a second way to check that we're at the same length to flip that tightrope. Sb now, to deploy our tightrope SB we can either pull on the implant or pull on the internal brace, as you can see here and now, if I go to pull on my graft, you can see that tightrope is flipped and it's not going anywhere. One nice advantage of the tightrope SB is that once we've flipped it, if we're not happy, or for some reason, we've flipped it on the outside of the Iliotibial band, we can actually elongate it and flip it by pulling tension on both sides of the suture, and we can watch it unfold and we can see we can pull it back down our tunnel and we can start all over. So this is a very nice advantage, which we can't do with our metal tightropes. And you can watch this go flip one more time again, holding both sides of the tightrope. Now that our tightrope SB is flipped on our lateral femoral cortex, we're going to shuttle our graft up into the knee. We'll watch it kind of go up into our femoral tunnel. And here comes our beautiful hamstring. Quadrupled graft link. And see our internal brace here. So graph going into our femoral tunnel we have marked it at 15 to 20mm. So we know how far to pull it in okay. So we have our graph passing to our femoral tunnel. Now we're going to pass it into our tibial tunnel. As you can see here. We're going to keep our tiger trailing sutures outside of the passing suture. We're going to send these down our tibial tunnel. We'll pull some of the slack out of our internal brace suture. And again, we've left behind our trailing suture because that's what allows us to pass our soft button in an elongated fashion. We can remove our femoral trailing suture at this point, because that side has already been docked, and we will hold some tension on our tibial trailing suture as we reduce the graft into the tibial tunnel. Now that our tightrope SB is outside of our tibia, we can remove our tiger trailing suture and our blue passing suture. Now we're ready to tension this inner tibial tunnel. So I have a small hemostat here to take some of the tension off our tightrope, SB, as we provisionally take some of the slack out of it so it doesn't bunch up too much. It'll allow it to lay a little bit more flat when we get down to our tibial bone. Now you can actually put a little pressure on that button and kind of flatten it or pancake it out on the tibial bone. So it lays a little bit flatter as we completely deploy it. And our final tensioning. So now we are going to fix our save sutures from our graph prep, along with the internal brace in our 4.75mm swivel lock anchor. So we have our swivel lock in that has fixed our saved sutures from our graft as well as our internal brace, and we can cut those and then we can still retension our tightrope SB on both the tibial and femoral sides to complete the procedure. So here's our final construct. We have our graph link ACL with tightrope SBS on both our femoral and tibial side with an internal brace technique.

GraftLink® ACL Reconstruction Using the TightRope® SB Implant for the InternalBrace™ Technique

Noman A. Siddiqui, DPM (Baltimore, MD), demonstrates a minimally invasive Akin osteotomy using a controlled percutaneous wedge cut to finalize the great toe alignment after bunion correction. Under fluoroscopic control, specialized burrs and a 3.5 mm bevel screw are used to main stability, while preventing soft-tissue trauma.

Minimally Invasive Akin Osteotomy for Bunion Correction: Surgical Demonstration

Speaker  To complete the hallux valgus correction. I always perform the osteotomy, and when I say always, I mean it nearly 95% of the time. I recommend performing the osteotomy to complete this. In this case, it's demonstrating a good example of a halux interphalangeus deformity, which contributes to the valgus position of the toe. So it's definitely indicated. But in general, after you do this correction, you want the toe to sit straight. That's what the patient sees. And it provides not only a clinical outcome that's better, but for the patient a cosmetic outcome as well. For my osteotomy, before I even make the cut on the bone, I get my wire started in the trajectory I would like to place my fixation. I utilize my incision that I use for the osteotomy of the metatarsal, and guide that 1.4mm guide wire to the base of the proximal phalanx. As you see here. Once I'm satisfied with the position, I advance it just a little bit X-ray, so it perches into the condyle there, and then I leave it there. And then I, in my mind's eye will think about an osteotomy perpendicular to the long axis of that wire. As you can see, I've placed the wire into the base of the phalanx. I've confirmed my position, the lateral view. And what I'm going to do with the osteotomy. The common error is to dorsiflex the phalanx. Once I complete the osteotomy, I want to make sure I keep it neutral to slight plantar flexion so I don't create an extension deformity of the phalanx itself. Speaker  I like to make my incision at the metadiaphysis of the phalanx. This gives me the benefit of the cortical strength as well as the metaphyseal bone for healing. And it allows me to greenstick the osteotomy really well. So my incision is made right down to bone, relatively percutaneous. I deepened that incision with a hemostat, and then I introduced the burr. The burr I'm utilizing in this method is the Shannon burr, which is two by two millimetres by 13mm. And I try to use this to complete the osteotomy in the dorsal planter and medial cortex while leaving the lateral planter hinge intact. Now, when you're completing the osteotomy, this can be done in a straight transverse fashion X-ray where you're doing a transverse osteotomy. You can oblique it through the same incision X-ray and create a larger wedge. Or you can orient this in a pattern that works for your screw fixation, but I try to be near perpendicular. And you can see here that that wire is going to be perpendicular to the the cut of the burr. I pinched the skin to move it away from the burr. A little reminder though our irrigation is not active, it is critical to all mis procedures. I've completed the dorsal portion of that cut. I'm going planter to complete that planter cut, and at this stage I want to make sure I hinge on that cut. Speaker  And I can test that initially by putting manual compression right at the osteotomy site and then take an X-ray X-ray. You can see I'm able to hinge that open X-ray, and then I can hinge it close X-ray. And if I want to kerf it just a little bit, I place the burr back in. And like I said, I want to hinge a little planter. So I'm going to make sure I'm removing a little bit more bone plantarly. And then I bend it a little bit more X-ray. I can see that I'm getting my correction. And at this point, I oscillate my wire and I'm making sure the toenail is sitting straight ahead. Oscillate that please. So let me see this. At this stage we've near perpendicular to our osteotomy line. And I can manually compress on this to kind of smush this corner X-ray. And that's what our compression will be. At this stage you can fixate with a non-compressive beveled screw or a compressive 2.5ft screw. I prefer minimal compression at this level. So I'm going to utilize the 3.5 beveled feet screw. At this stage you can see we've corrected the mechanical axis of the first metatarsal. We've corrected the halux interphalangeus deformity in the phalanx. And what the benefit of this correction is the soft tissue realignment at the extensor tendon at the capsule, and a more rectus digit, which is minimally invasive, cosmetic in appearance and allows the patient to weight bear immediately.

Minimally Invasive Akin Osteotomy for Bunion Correction: Surgical Demonstration

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

Arthrex Variable-Angle Proximal Tibial Plating System

Arthrex Variable-Angle Proximal Tibial Plating System

At the Women in Hand, Wrist, and Elbow Surgery course,&nbsp;Julia Nuelle, MD&nbsp;(Columbia, MO), discusses the evolution of surgical advances towards suspensionplasty for the treatment of CMC arthritis, including a review of the surgical technique and supporting literature.
The&nbsp;InternalBrace™ surgical technique is intended only to augment the primary repair/reconstruction by expanding the area of tissue approximation during the healing period and is not intended as a replacement for the native ligament.The&nbsp;InternalBrace technique is for use during soft tissue-to-bone fixation procedures and is not cleared for bone-to-bone fixation.

Evolution Towards Carpometacarpal (CMC) Suspensionplasty for Thumb CMC Arthritis

OrthoPedia: Evolution Towards Carpometacarpal (CMC) Suspensionplasty for Thumb CMC Arthritis

Darien W. Bradford, MD (Dallas, TX), discusses the benefits of using platelet-rich plasma (PRP) in sternotomy closures and provides a case example of how he incorporates PRP into his procedures.

Use of PRP During Sternotomy Closure

Hello, my name is Darrien Bradford. I am from the Dallas Fort Worth area and I'm here to discuss why we use platelet rich plasma. So why PRP? Well, we know that PRP is important in terms of healing and wound healing as far as we're concerned. We have known for many, many years that there's a healing triad that goes along with what happens with the PRP and also with the platelets that we know that secrete alpha granules and also dense bodies. They play a role in the inflammation process and also proliferation and remodeling. When you think of platelets, you want to think of growth factors. Things such as pdgf, TGF, VEGF and also things like fibronectin and many, many more. Platelets also have microtubules and also filaments that help to maintain the platelet shape and also assist in clot retraction. So why add PRP to sternal closures? We've seen in this study that there has been a reduced incidence of deep sternal wound infection from 2% to 0.6% and superficial sternal wound infections from 8% to 2%. There's also a reduction in costs associated with the development of deep sternal wound infections, and also superficial sternal wound complications from 1.26 million down to 594,000. Readmission rates were also reduced from 4% to 0.8%. They also evaluated with the treatment of PRP. They saw a significant decrease in bacterial growth after eight hours and after 24 hours. Prp preparations with low leukocyte concentrations may produce equal antibacterial effects relative to the preparations which produce higher leukocyte counts. And the second study, they saw a decrease in colony forming units of Mssa, MRSA and Group A strep in the first two hours. When treated with PRP and thrombin and in vitro angel technology utilizes centrifugation and principles of cytometry. Cytometry is the principle of cell identification using cell specific wavelengths of light. This is the Angel PRP system. With a system, you can titrate and use anywhere from 40ml to 180ml of blood drawn. Use of anticoagulants is recommended. There's an automated process, and the centrifuge is actually built into the Angel system to be able to create a buffy coat based PRP, leukocyte rich or poor. And you can also adjust the hematocrit. Also, it processes both peripheral blood and bone marrow. This machine was designed with perfusionist in mind. The ability for Perfusionist to be able to manipulate the machine while in the middle of a cardiothoracic case can be very time consuming. So one of the ways we reduce that is by the use of this machine, which is very self-explanatory and allows for them to be able to collect the PRP and platelet poor with relative ease. Here we see the user interface, which allows you to be able to collect certain volumes and also dial the hematocrit in that you want to concentrate to our specific protocol at our hospital. The Perfusionist loads the processing set onto the Angel system. 180 cc's of whole blood is drawn before the incision is made. I use 25% hematocrit that is stored under my protocol. Once the system is done processing 20 cc's of PRP and 20 cc's of PGP is delivered to the sterile field. Ten CCS of calcium chloride is mixed with 10,000 units of thrombin. I prefer to use the 11 one recombinant thrombin sources. Here we see the actual application process of the PRP on the sternal edges. And here we also are. At the end of the case we are placing the PRP between the two sternal edges.

Use of PRP During Sternotomy Closure

This animation reviews a thoracic transforaminal approach for discectomy procedures, which is performed with the Synergy Vision™ imaging system and a spine-specific endoscope. It also highlights the unique WishBone™ instrument handle, which is designed for improved ergonomics, and FlexTip electrosurgery probe.

Thoracic Transforaminal Endoscopic Discectomy

The endoscopic thoracic transforaminal discectomy approach from Arthrex is an ultra minimally invasive surgery ideal for patients with certain thoracic disc herniations. In this procedure, the endoscope is used to assist in the approach for access and visualization. The patient is placed in the prone position using an orthogonal AP fluoro image. Draw a line at the midline. Then draw a line through the center of the disc. Next, from a lateral view, mark a line to the front of the disc space, giving an orthogonal view of the disc. Mark the apex of the rib, which is the lateral boundary for making the incision point and needle insertion. Insert the needle at approximately 35 degrees, depending on the location of the disc. Pathology. Make an incision along the along the introducer needle. Next, insert the guidewire and remove the needle. Insert the dilators while rotating. Next, insert the cannula while rotating with the open side towards the foramen. Remove the dilators and insert the endoscope. Use the cup graspers and the flex tip bipolar probe to identify bony landmarks and remove soft tissue to expose the foramen. Use a bird to resect a portion of the inferior pedicle to create a working channel for the endoscope and cannula. Next, if necessary, to reach the midline, create a trough from the superior end plate to the inferior end plate through the disc and above the disc in the vertebral body. When the working channel has been created, the space underneath the cord allows for removal of any fragments ventral to the cord using a downward and outward motion. Confirm the decompression has been completed using direct visualization and palpation. The endoscope and cannula are then removed, followed by wound closure and placement of a JumpStart bandage.

Thoracic Transforaminal Endoscopic Discectomy

Misty Suri, MD (New Orleans, LA), presents a second-look surgery 6 weeks after CuffMend™ augmentation, showing incorporation and vascularization of ArthroFlex® human dermal allograft.
ArthroFlex is a registered trademark of LifeNet Health.

CuffMend™ Rotator Cuff Augmentation: Second-Look Surgery at 6 Weeks

Hi, my name is Misty Surrey from New Orleans, Louisiana, and I'd like to share with you a cuff mend second look case. So our patients, a 40 year old male, he's a military recruiter and he's a recreational bodybuilder. He came in with left shoulder pain after an incident at the gym. Basically he was lifting. He had a pop in his biceps three weeks prior to presentation and he came in. So at this point on physical exam, he had pain in his biceps. He had pretty good range of motion. He was just a hair weak in his rotator cuff and a positive near positive. Hawkins and O'Brien signs on x ray. Nothing significant. No significant arthritis or dislocation or any bony changes. Now an MRI. What we see here is a small ten by ten millimeter partial thickness under surface. Tearing to the rotator cuff did have an upper border sub scap tear with a slap as well. So at this point I decided with the patient that we would proceed with a biceps tenodesis a slap repair, and to address that rotator cuff damage cuff mend augmentation of the partial thickness tearing. So in the operating room, what I found was a type eight slap. There was no evidence of any damage, and the partial thickness rotator cuff damage was confirmed. That we saw in the MRI was about 30%. On the articular side of that rotator cuff, I proceeded with an upper border subscapular repair and a decompression and a repair of that slab. Type eight to address the partial thickness articular sided cuff damage. I proceeded with a cuff mend augmentation of the rotator cuff. So here's a clip of the cuff augmentation part of the procedure. I attached the graph medially with fiber stitch RC anchors both anteriorly and posteriorly with a mattress stitch. I do prefer to use the nanoscope with this part of the case, so I can see the implants deploy on the undersurface of the rotator cuff. I used the two fiber stitches medially, and then two push locks laterally to fix the cuff bin graft. Here's what the final augmentation looked like with the graft nicely tensioned and not over tensioned. So unfortunately, five weeks after surgery, the patient fell and then fell again and had a Popeye deformity that he noticed after the second fall with a significant increase in pain. So he came in and on physical exam. At this point, he had a positive Popeye deformity with a positive speeds and positive Jurgensen signs, as well as a little bit of weakness and decreased range of motion. So an MRI was obtained at this point showing complete disruption of the proximal biceps with about three centimeters of retraction, as we can see here. And the superior aspect of the subscapular was torn as well. So at this point, the plan was to do an open subpectinata thesis with a revision repair of the superior aspect of the subscapularis. So the intraoperative finding confirmed the MRI findings of the torn biceps and the upper subscapularis tear. So I proceeded with an upper subscapular revision repair as well as an open subpectinata thesis. With the second look, I was able to see the great incorporation of the kerfman graft into the rotator cuff tissue. So to probing here you can see the the continuity of the graph to the native tissue, as well as the vascularity of the graft already at the six week time point. Now there is no inflammatory reaction at all. There was no bursitis. This is what it looked like when I put the scope in to the shoulder. So this was this is a very, very convincing second look that shows us great incorporation of this graft at this time point of six weeks. So what happens on the undersurface of the rotator cuff? You can see the complete synovial ization of the implants on the undersurface of the cuff, with no reaction whatsoever. So at the six month time point, he's doing very well. He's quite happy. He has a sane score of 90, he has zero out of ten pain and he's back to weightlifting. His motion is very good and he's got great strength in terms of cuff testing. So this was not an isolated case. I had another patient that also had a subsequent trauma after surgery that we got histology on as they went on to a shoulder arthroplasty after their massive rotator cuff repair that was augmented with cuff meant. And we can see here that there's significant revascularization, active tissue remodeling and decellularization of the graft. This was another patient, also seven months out of surgery that had an AC joint trauma that I got a second look on. That also shows excellent incorporation of the Kauffman graft. To conclude, Kauffman has been a game changer in my practice. With my experience of over 300 cases, I have found Arthur Fleck's to be the perfect combination of mechanics and biology. It's been a paradigm shift for my patients, giving my patients the best chance of healing of their rotator cuff tissue. Thank you.

CuffMend™ Rotator Cuff Augmentation: Second-Look Surgery at 6 Weeks

Noman A. Siddiqui, DPM (Baltimore, MD), provides a step-by-step surgical demonstration of the Arthrex MIS Bunionectomy System with the triangulation guide, focusing on critical anatomic landmarks, fluoroscopic cues, and practical tips and tricks. The goal is to shorten the learning curve, improve OR efficiency, and deliver consistent correction, helping surgeons build confidence in adopting and performing minimally invasive bunion surgery.

Building Confidence in MIS Bunion Surgery: Practical Tips, Key Landmarks, and Fluoroscopy Views

Building Confidence in MIS Bunion Surgery: Practical Tips, Key Landmarks, and Fluoroscopy Views

Sanj Kakar, MD (Rochester, MN), shares how the NanoNeedle™ scope 2.0 can aid in visualization during wrist arthroscopy procedures.

SpeedPearl: DRUJ Arthroscopy Using the NanoNeedle™ Scope 2.0

Speaker  The trampoline hook and suction test provide an indirect assessment to the foveal insertion of the Tfcc, which is the most important static stabilizer of the Druj. Given how tight the DJ is, the Nanoneedle provides an ideal indication for its use to examine this space and the Foveal insertion of the Tfcc. Using the percutaneous kit, you can access the DJ in a safe and efficient manner.

SpeedPearl: DRUJ Arthroscopy Using the NanoNeedle™ Scope 2.0

Carl T. Hasselman, MD (Pittsburgh, PA), demonstrates the BunionBrace™ surgical technique to augment and reinforce a direct repair to the medial capsule during hallux valgus correction. In this case, the procedure was performed alongside a Lapidus procedure using an I-beam plate. The BunionBrace technique aims to reduce the chances of recurrence of a valgus deformity at the MTP joint. Weakness in the joint capsule can be a mechanism for recurrence of the deformity. Augmenting the capsular repair using the BunionBrace system aims to increase the strength of the primary repair.

BunionBrace™ Medial Capsule Repair Surgical Technique

Speaker  As you all know, a lot of times we'll do that medial capsule repair and we'll be really happy with it. And then all of a sudden, at about 2 to 3 months or four months, you start seeing the valgus recur. Even though your Im angle has stayed the same. You just see that medial capsule repair start to fail. This is a nice way to augment that repair, to make sure that you don't get failure of the medial capsule repair. And so we're going to basically take you through that technique. So all we've done so far is we've made our exposure. This is your metatarsal head. We've already resected the medial eminence. This is going to be your proximal phalanx. You're going to basically do a hallux valgus medial capsule repair. And then we're going to augment it with the bunion brace. So the Arthrex bunion brace consists of a fiber tack and a three five swivel lock. The fiber tack will go into the proximal phalanx, and the three five swivel lock will go into the metatarsal head. So for the placement of the Rd fiber TAC, basically you're going to want to go 3 to 4mm distal to the articular portion of the joint. So right now I'm on the joint. So I'm going to go distal about 3 to 4mm. I want to make sure I'm midline. I try not to go too far. Dorsal too far plantar. I kind of want to stay midline so that I will follow the arc of motion of the first MTP joint. Speaker  The other thing that's nice is by only going 3 to 4. This is just a 1.6 wire. So it's very small. So if you wanted to do an Aiken at the same time, you would still be able to do that. So now I'm going to basically take my drill. I'm going to basically drill my 1.6. I'm angling away from the joint. And then at that point we're going to place our DX fiber tack. And so all we're going to do is now we're going to pull straight back, try not to wiggle back and forth, and then you're going to give it a tug. And now you feel comfortable. That's seated. The nice thing is, is if I grab it, you should feel like you can grab that phalanx and pull. And so you've got a good seating of the phalanx. Once we have that completed, we're going to put this out of the way. We're going to now go to the metatarsal head. And what we're going to do is you can see that we've shaved the medial eminence. And so this is the end of the medial eminence resection right there. We're going to go 3 to 4mm just proximal to that. And so once we have that we're going to feel dorsal plantar. I want to make sure I'm midline. And then what I'm going to do is I'm going to place that right where I want to be. Speaker  And then we're going to drill. And then once we do that, we're going to tap. And you can see there's a black line just like in the ankle. Basically, the first thing we're gonna do is we're going to do our soft tissue repair of the capsule. I think for the sake of this video, I'm literally just going to do a side to side repair of the capsule so that people can get an idea of what we're going to do. But in this case, I'll just do a rapid side to side repair of the capsule. So now that we've had our primary repair of the capsule completed, we're now going to pass our collagen coated suture tape. We're going to do two different limbs. We're going to take limb one and we're going to go more superior along till we get to the metatarsal, and then our second one will go more plantar along this area. So we're going to do is pass our collagen coated suture tape. Again, I'm passing it. And you'll notice as I pass I'm going to exit just about where my metatarsal hole is for my swivel lock. And so we've got this passed. The nice thing is with both of them, we're now right where we want to be because the hole is right there and I'm ready to pass these. So once we've cut the needles off of our suture tape, basically what we're going to do is we're going to thread them through the islet of our swivel lock. Speaker  We're going to pull it down. There's two ways to do it. One is you can just tension it the way you like and insert the swivel lock. But the other thing you can also do is a marking technique. The nice thing about this is you can actually now start to insert your swivel lock, and you're just going to put pressure on the swivel lock to make sure it seats itself in. So now that you have the swivel lock actually pushed into place and you're happy with the tension. You want to make sure that the swivel lock is flush with that medial cortex. You do not want to bury it under there because as you look, you can see there's just a small aspect of the swivel lock exposed, but it's right to that cortex that gives you a good fixation between the swivel lock and the medial cortex of the first metatarsal. You can test your tension right now. Make sure you're absolutely happy with the tension just by pushing down on the great toe. So once you're happy with this and you think you've got good tension, I'm going to push down on the toe. I like how it springs back and it has a nice. Now I can go ahead and cut my sutures off. And literally we're going to kind of go right down flush because you don't want these exposed. And now you have your repair. And so now that you have your final construct in place, if you look closely and I pull back, you can just see the sutures in the capsule here. Speaker  You can see how the bunion brace actually maintains that correction. The suture tape actually holds that so that your soft tissues don't get stretched during the final repair. This is great if you don't have much capsule to work with. A lot of times, especially in our elderly population, you don't have that capsule to work with. This is a great way to augment it, but I also think it's a great way just to augment all your repairs, because it's going to prevent that late migration that we see sometimes, once this is finally completed and you have your closure. The nice thing is the kit also comes with jumpstart, which is an antimicrobial dressing, which very nicely can be put on there and again, put on to prevent infection. And it works very well. So now basically we have our final construct. You can see our health balance is corrected and we have our bunion brace in place. So now what I'm going to do is just show you real quick that we can actually on live flora, we're going to go ahead and test that. And so you'll watch as it goes. And I let go. It springs right back into action. So I can stress my repair and I let go. And it's going to go right back to where it belonged. And that's a nice repair.

BunionBrace™ Medial Capsule Repair Surgical Technique

Bruce A. Levy, MD (Orlando, FL), leads a discussion with panelists Matt Daggett, DO, MBA (Kansas City, MO); Seth L. Sherman, MD (Redwood City, CA); and Patrick A. Smith, MD (Naples, FL). The panel reviews evidence-based factors for adding a lateral extra-articular procedure (LEAP) during anterior cruciate ligament (ACL) reconstruction, emphasizing risk factors such as graft choice, high-grade laxity, hyperextension, youth, participation in pivoting sports, and revision status.

Lateral Extra-Articular Procedure (LEAP) Consensus Statements for 2026

OrthoPedia: Lateral Extra-Articular Procedure (LEAP) Consensus Statements for 2026

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OrthoPedia: Managing the Subscapularis and Biceps Tendon

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Synergy Power™ System Product Demonstration

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FiberTape® Sternal Closure for Rib Approximation After Thoracotomy Incisions

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