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NanoNeedle™ Scope 2.0
Gains National Spotlight Through

Star MLB
Pitcher's Recovery

Sanj Kakar, MD (Rochester, MN), shares a surgical pearl for using the NanoNeedle™ scope to mitigate iatrogenic cartilage injuries in the radiocarpal joint.

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English  - en

video

SpeedPearl: Accessing the Radiocarpal Joint With the NanoNeedle™ Scope

Speaker  Given its small diameter and flexibility, the Nanoneedle mitigates any echogenic cartilage injury. Typically, I create the three four portal first as my viewing portal and the six portal for instrumentation. For the over-the-top tfcc repair procedure, however, it's important that these portals are reversed since the scaphoid tends to flex and pronate with scapholunate instability. I typically create the ulnar Midcarpal portal first, followed by the radial Midcarpal portal.

SpeedPearl: Accessing the Radiocarpal Joint With the NanoNeedle™ Scope

Peter Borden, MD (Torrance, CA), demonstrates repairing a small rotator cuff tear using Self-Punching Double-Loaded Knotless 2.6 FiberTak® soft anchors.

Small Rotator Cuff Repair Using Double-Loaded Knotless 2.6 FiberTak® Soft Anchors

Hi, this is Peter Borden from Los Angeles, California. I'm going to demonstrate with you today the use of the 2.6 FiberTak anchor. Using two anchors for a simple rotator cuff repair. This is a left shoulder, and we have a small laterally based tear. We are going to plan to put one anchor here and one anchor here, right on the edge of the greater tuberosity here. We are going to repair that in a single row fashion. For this case we're utilizing the NanoScope. We've got this ultra wide NanoScope view currently of the greater tuberosity and the small cuff tear. You can see the extent of the cuff tear, but you can see the entire greater tuberosity from front to back in this one view. I can show you with a press of a button that we can cycle through a 70 degree view, so we can look at it from the side standpoint. I can also cycle away from that and do a standard 30 degree view as well. But notice how when we go to the Pano view, we just get a much more global view of the greater tuberosity. Here we've added an ASL portal for suture management. I would like to be able to put both anchors. One anchor here and one anchor here. We're going to go ahead and retrieve our working sutures one at a time, out our lateral portal, and then we'll take the Scorpion. I'm going to add the working stitch to the side loader as we come in. So I'm going to go ahead and take a feel and see how much cuff tissue I want to grab. And I want to pull and reduce. I'm going to go into the anterior extent of the tear. That looks good. I'm going to do one there and let's go ahead and pull that. So we got the first pass done. I'm going to move that out of our working portal for suture management. So now we'll retrieve our blue white working stitch. We will add the second working stitch to the Scorpion. We're going to hold our suture and do our second pass, making sure we stay on the correct side of all the sutures. And we're going to come in and we're going to make an analogous pass. And I'm going to take all these and for suture management purposes, and we're going to take everything out of our ASL portal. There's our passes. So now we're localizing our posterior anchor placement here. So I want to be right off the edge. Kind of similar to my other anchor. And then I'll check the anchor again and make sure I can lift the arm up and I can. So we placed our anchor. We're going to retrieve the black and blue working suture. Now we're going to load a Scorpion passer. We will take a look at our spread. So I don't want to hit the other suture from the first anchor. So I'm going to keep an eye on everything. I'm going to go in, go above it, look and see where my other pass was. There's my other pass. I'm going to go just adjacent to that. So we're going to come in and we're going to go ahead and take our second pass. We will fire it, retrieve it. So we got two sutures there. We're ready to convert. So I'm going to go in I'm going to retrieve this guy. We have the loop suture for conversion of the anchor. At this point I'm going to go ahead and take this. Put it through the loop. And we're we'll make sure that it's where the purple mark is. That's the purple mark. Both sutures are through the shuttle loop, and I've got this ready to go. So I will go ahead and convert this. We will utilize the shuttle suture in order to put a little tension on the loop on the working repair sutures so that we have a little counter tension and this little counter tension that we're doing on here. It just helps us keep this from getting all twisted up. And as I bring it in, look how nice and straight it kept my repair sutures on that tissue. And now that I've got this scenario here, I could remove this suture that was helping me maintain the orientation of the sutures. And now we're going to take both of these sutures, and we will go ahead and seal that down to bone. We will go ahead and use the Mega loader to load our repair sutures in the cutter, and we'll come in and we'll go down to the anchor, give another little gentle tug. Now we'll do the same thing with the other sutures. So that's perfect. We will cut this suture and get out of here. We've got this single row, lateral row repair of the rotator cuff. We've got great fixation of the cuff tissue to the greater tuberosity.

Small Rotator Cuff Repair Using Double-Loaded Knotless 2.6 FiberTak® Soft Anchors

Peter C. Yeh, MD (Stoneham, MA), shares a surgical pearl for using a weighted clamp to optimize graft passage during all-inside ACL reconstruction.

SpeedPearl: All-Inside ACL Reconstruction Using a Weighted Clamp

All-inside ACL reconstructions require a level of precision and preparation, as proper graft and suture management are keys to ensuring a smooth case. Here's a simple but very effective way to pass the graft into the femoral socket. Rather than having an assistant's hand pulling on the tibial shuttle loops, I use two clamps to weigh down the tibial shuttle loop suture that comes out of the Am portal and tibial incision, taking advantage of gravity to tension it down and out of the way. The heavier the clamps, the better. This allows for ease of graft passage, but more importantly also frees up an assistant's hand to do something else to further the case. One clamps both sides of the tibial shuttle, stitch both the Am portal side as well as the tibial incision side. For extra weight, I put an additional clamp on just the suture loop coming into the Am portal to make it even heavier. This allows tension on the suture and allows for the passage of the graft without worry that the tibial shuttle sutures will get pulled in.

SpeedPearl: All-Inside ACL Reconstruction Using a Weighted Clamp

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

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

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

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

John Zvijac, MD (Miami, FL), demonstrates the use of the NanoNeedle™ scope 2.0 and the PassPort Button™ cannula with auxiliary lumen for Nano shoulder arthroscopy labral repairs.

Labral Repair Using the NanoNeedle™ Scope 2.0 and the PassPort Button™ Cannula With Auxiliary Lumen

Speaker  Hi, I'm John from Miami, Florida, and today we're showcasing a label repair technique using the Nanoneedle scope 2.0 and the accessory Lumen Passport. This setup allows for ultra minimally invasive access and enhanced maneuverability. We've already established our portals, and the accessory Lumen Passport is positioned to facilitate suture management and instrument passage. You'll see how this design improves efficiency and flexibility during the repair. Here is what the accessory Lumen Passport looks like. We have a center hole for instrumentation, and then there is an accessory lumen, which allows for passage of a multitude of micro instruments for suture management. Here we see the nanoneedle scope in the posterior shoulder portal and the accessory passport lumen anteriorly in a rotator cuff interval. A little pro tip the accessory portal. If you can leave this inferiorly or posteriorly, it makes it a little bit easier for suture management. It's not that big of a deal. You can always put it in any position, but that's a little pro tip to help as you're moving this along. You can see the soft tissue bankart lesion that's occurred. This is the labrum all the way down. And we're well past the 6:00 position to allow for bringing the capsule both superiorly and laterally onto the articular surface. The labrum often falls not only medially but inferiorly while you're doing these type of surgeries. Speaker  So it's important to free all of this up for proper mobilization and tensioning. We'll be repairing this labral tear with the 1.8mm knotless fiber tack anchor. This is being done through the central lumen of our passport. And now we're going to pass the suture retriever through the accessory portal in our passport. You can see it coming through, and we can easily pass our stitch with the use of a scorpion through our central portal. And now we're going to just easily shuttle our loop stitch through our center portal. And now we're ready for shuttling a repair stitch. Keeping very nice suture management, preventing entanglement of the stitches intra articularly. We're going to take this stitch out through our center hole to allow for final cutting of the stitch. Here we're using the flush cutter, and we can just bring this down to central portal. And we can cut our stitch flush. And we're ready for the next stitch. The repair is completed with precise suture placement and minimal disruption to the surrounding tissue. The accessory Lumen Passport enhances suture management and expands our instrument options for suture passing during a label repair. Combined with the Nanoneedle scope 2.0, we're moving closer to an ideal solution for the ultra minimally invasive arthroscopy.

Labral Repair Using the NanoNeedle™ Scope 2.0 and the PassPort Button™ Cannula With Auxiliary Lumen

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

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

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

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

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

This testimonial video spotlights a variety of surgeon insights on the impact the game-changing enhancements within the Syndesmosis TightRope® PRO implant brings to their practice.

Going Pro With the Syndesmosis TightRope® PRO Implant

Speaker  So how do you make the best better? Well, in my hands, I have the new tightrope probe. There's a huge cool factor to this. And time and speed and efficiency. Speaker  The tightrope has been the single biggest game changer in my practice since I started. It's an implant that has really changed how we get athletes back on the field. Speaker  It's the perfect blend of old and new. It really respects the legacy of the original tightrope, and the tightrope. Xp combines that with Arthrex continued commitment to innovation. Speaker  It comes apart in your hand and comes together in a way that the pieces are already attached. We pull on this black part here. It pushes the button down automatically and secures it without any additional step. Speaker  A more efficient process from one minute down to 30s. Lower profile drill tunnel. Lower profile medial and lateral buttons, and an updated instrumentation. This is really a new game changer. Speaker  I've always been a tightrope guy, but this new tightrope pro is incredible. Everything has just been refined. You combine the engineering, the design with level and evidence. You've got the tightrope professional.

Going Pro With the Syndesmosis TightRope® PRO Implant

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

J. Lee Pace, MD (Plano, TX), demonstrates a technique for medial patellofemoral ligament (MPFL) reconstruction using onlay patellar fixation with Hybrid Knee FiberTak® anchors and femoral fixation with the FiberTag® TightRope® II PF implant.

Patellar Onlay Technique With Suspensory Femoral Fixation for MPFL Reconstruction

Hello, my name is Lee pace from Plano, Texas. I am an orthopedic surgeon with a specialty in sports medicine and knee surgery, and I'm here today to show the new Mpfl reconstruction technique using a patellar inlay technique as well as a new mpfl fiber tag tightrope for femoral fixation. So we have a graft here on this disposable graft prep and sizing table. And this is really nice when you're using autograft tissue because you can use this as we're going to show here to scrape muscle off just like this. This stuff just comes right off. Just like that. You can see you can really very easily get all that muscle off of a tendon when you're doing your mpfl reconstruction. So here we have a prepared gracilis graft for an mpfl reconstruction. We want to make sure that this portion of the graft is going to fit through a six millimeter femoral tunnel. So we're going to size that right now. So we're just going to bring this through here and pull this up. And there you can see that that fits very easily through that. We can probably pull that all the way through just like that. So we have a good graft size here. And then another thing to highlight on this graft prep table is at any point during graft prep, if you if you need to or want to, you can actually use these cleats to be able to hold the graft steady and add some tension. So I can just wrap this around here just like this. And now this one side of the graft is is going to be held stationary just like that. And then also if I want to I can also do the same thing on the other side as there's cleats on both sides of this graph prep table. So we've done a standard medial two incision approach for an mpfl reconstruction. Here is our femoral incision right here. That's typically going to be made under fluoroscopic control. Here is our patellar incision. And you can see we've got the medial aspect of the patella exposed. There's a medial patella. There's the joint right there. You can see I've marked out our anchor placement. This is about midway on the patella. And this is about 25% down from the superior pole. So we're going to place an anchor here and here. And then we're going to do an on lay technique to secure the graft between these two anchors. So here is the knee fiber tack ratcheting guide that we're going to use to drill our patellar sockets as well as place our anchors. So you can see this has a ratcheting mechanism with a release mechanism right there. And it's got a spike on one side. And that is meant to anchor in to one side. You can do this percutaneously and just kind of stab through the skin. Or if you would like to, you can also get an idea of where you want to put it. And you can make a small stab incision like this. So usually you want to start and get the lateral side in first. So I'm going to get this down. I can feel very firmly that I am on the lateral aspect of the patella. And then this just simply ratchets down. And I'm going to put this right over my purple mark. So I've got the ratcheting fiber tack guide in place. You can see that it's secured against the lateral patella and the medial patella. So I can kind of move the patella back and forth like this. This is very secure. This will allow very reproducible socket drilling as well as anchor placement. This is just going to bottom out. And then this fiber tack has a blunt inserter to allow for easier insertion on the mobile patella. Take this off. Move this. And then the anchor is in. And now I'm going to set it. So I'm going to pull. And you can see that that is very firmly in place. That is not coming out. Okay. So then I can place the second one. So I'm going to just kind of put it over the spot where I want to put the second anchor. I'll take a second. I'll make sure that that gets right down on the patella. That's very firmly on the patella right there on the lateral patella. We're going to come in here and we're going to just retract that up just a little bit. So I can see where that second mark is. And that looks good right there. Ratchet that down again. You can see very firm control of the patella right there 2.8mm hard bone drill. Bottom it out. And then look at that. Look at how much that actually inserts just with hand pressure. Finish it off with the mallet. And now we'll set this anchor. And again that is firm in there that is not pulling out. Okay. We're going to drill and prepare the femoral tunnel next. This is the Radiolucent Fluoroscopic guide for Shuttles Point which you can use at this point with lateral fluoroscopy. We've already determined where we want our femoral socket to be. So we're going to then take our Beath pin our spade tip Beath pin. And we're going to drill this across the femur. That's just going to poke out the skin of the lateral thigh. So now we can take our low profile six millimeter reamer. And we'll take that over the Beath pin. And you can honestly just take this to the next cortex and don't violate that. But that way you've got all the room you need in case your graft is a little long. And then from there we can switch this out to a fiber snare. And then we can just luggage tag this for later. Okay. Now we're going to fix our allograft on the patella. We've made a mark here at the midway of the graft like so. The first thing we're going to do is we're going to shuttle it through these two loops. Okay. And then we can just start tensioning this down. And we just take it each one at a time. And we're just going to make sure that as we get close that we keep that midpoint in between these two loops. And as we bring it down, you can see we've got our purple midway point basically perfectly between those two. And so we can just continue to cinch that down and cinch that down like that. And so we've got very good fixation now of that gracilis graft right on our medial patella. And you can see I can pull very firmly on that. And those anchors are not coming out. We've got very good onlay fixation of that graft on the patella. Now the next step, we're going to take a little measurement of how much gracilis graft we still have. You see if I can drag it down here that it is definitely going to be long enough. The question is, is it too long? The answer is probably not, because we have such a long femoral socket. But if we want to take an extra measure of precaution, we can measure how much length we have here. And you can see that we've got almost 9cm or 90mm of length. And we know that the mpfl is roughly about, on average, 65mm long. So if we want to, we could actually shorten this graph down. Maybe a centimeter, centimeter and a half. And we know that we're still going to get probably, you know, 15, 10 to 15mm of graft inside the femoral socket. So once we've kind of made that determination, if we do want to shorten it or if we're happy with what we've got, we can then remove our graph prep sutures and we can apply our fiber tag tightrope. So next we are going to fix this new mpfl fiber tag tightrope to the free ends of this gracilis graft. Okay, so the thing to point out is that this fiber tag is slightly smaller than what you would use for an ACL. So this is designed specifically for an mpfl reconstruction. And so what we do is we take this off of this backer card just like this. This will unroll. And this comes off. And now we've got this. And this is going to be very similar to an ACL reconstruction. So I'll take the tenaculum clamp next. And so this works just like it would for an ACL is we're going to take keep this little slot on top right there. Keep that little slot on top. This is going to feed into that. So we have the fiber tag now snared through the superior jaw of the tenaculum. And then once we have that then we can get the graft and we can pinch it all down together just like that. Okay. And then from there, it's just a basic suturing exercise. And now once we've got this, take the tenaculum clamp off, and then we can just simply just remove this just like that. And now we have our loop and we have our pull stitch, and we have our tightening sutures right here you can see that this loop is a little short. So we are going to lengthen it to make sure we have enough to get across the distal femur. So that should be we just even this out a little bit. That should be enough to to get us across the distal femur. The last thing to point out is that this is like the original tightrope, in that the tensioning sutures are actually going to be back here, and we're going to tension through the medial side. It's not going to be like an HT tightrope where we're tensioning on the lateral side. Now as we get ready to pass we can go ahead and we can cut these sutures right here. Now we're going to dissect out the plane between layers two and three, so that we can pass the graft from the patellar side down to the femoral side and then shuttle it into the femoral tunnel. So just dissect down like this. And I often will just get my my finger in here and just make sure that I can feel my scissors. I also want to make sure I do not cut my suture and I am. So now we're going to take a snare, bring that up, and then we're going to take all of our suture. Fold it over. Pull it down just like that. Okay. And now what we're going to do is we're going to take our blue sutures only. To pass the graft into the femoral tunnel. Okay. And now we can pull that through. Let me take this. And I'm just going to hold a little bit of back tension here. Okay. Go ahead and pull the button through. And you can do this with fluoroscopy in a live situation to make sure your button flips properly. But it feels like we just got the button through. So I'm going to just kind of pull back. And again we can usually check this with fluoroscopy, but it feels like the button is flipped because I am pulling back on the graft and I'm not getting anything to come back on me. Now we are just going to tighten the adjustable loop of our tightrope. So I like to have an assistant hold this. And we'll just shuttle this down until we're close. And I'll usually stop there. And then we'll bring it up through the under the patellar side of things. And this is my check rein to make sure that I don't over tension it. So I've got the knee flexed roughly 4550 degrees. That way, the patella is solidly engaged in the central to distal trochlea. So I know it's exactly where I want it to be. And now this is going to prevent me from over tensioning the tightrope. So if we look you can watch the graft tension over the clamp. Just like that. And once you feel like you've got some resistance there. Again, this prevents this allows you that one quadrant of translation. Once you've got a little bit of residual slack, you can then take it out. And then you can check your translation. So you can see here that I've got still about a quadrant of lateral patellar translation. So that's going to be pretty perfect. That's exactly what we want. So this is our way with this clamp to minimize the chance of over tensioning. It makes the tightrope technique very reliable. Now, typically what I would do at this point is I would take the knee through a range of motion, and I would confirm that there was no increased tension on the graft in deep knee flexion. And if that is confirmed, we can then proceed with cutting these sutures. We can remove the blue pull stitch. And now we can use these sutures to close our retinaculum. This is a 1.3mm suture tape. And as you can see this is all one long suture with a needle on either end. So we can come through the retinaculum here. So you can see the final retinacular closure here is complete. We've got good knots placed here and that is completely closed down.

Patellar Onlay Technique With Suspensory Femoral Fixation for MPFL Reconstruction

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

Distal Biceps Tendon Repair Using the TensionTight™ Button

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

Distal Biceps Tendon Repair Using the TensionTight™ Button

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

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

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

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