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Christopher Adams, MD (Naples, FL), and Misty Suri, MD (New Orleans, LA), demonstrate the technique and order of operations for combining a rotator cable reconstruction with a biologic tuberoplasty to treat massive irreparable rotator cuff tears. They briefly review the demographics of a surgical candidate for this combined procedure.

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Posterosuperior Rotator Cuff Tears: Rotator Cable Reconstruction With Biologic Tuberoplasty

Hello, my name is Chris Adams and I'm with Misty Surrey. And today we're going to demonstrate the technique for combining a cable reconstruction with a biologic tuboplasty for the treatment of massive, irreparable rotator cuff tears. Now we consider cable reconstructions in patients who desire an attempt at fixing their native rotator cuff, has significant comorbidities, or do not want a reverse shoulder replacement. Misty, what about biologic tuboplasty? Well, Chris Tuboplasty is also reserved for massive, irreparable rotator cuff tears, but we specifically seek patients who are painful but have preserved range of motion. We prefer those with Hamada 1 or 2 without any arthritis. They need an intact or repairable subscap and can't have any pseudoparalysis or external rotation lag. The beauty of these two techniques is that they can be done together without adding significant surgical time, or burning any bridges for the future. I agree, but people often ask when would you combine them? Well, we start with the biologic tuboplasty patient with no arthritis. Hamada 1 or 2 with preserved motion. Who desires pain relief? The purpose of adding a cable reconstruction is to improve the kinematics of the shoulder, and to potentially improve the patient's strength and function, and to preserve their native shoulder for as long as possible. Now let's see how it's done. So you can see here we have a right shoulder glenoid on the left humeral head on the right. We see that we have an irreparable rotator cuff tear. If we pull over, you can see that it's just too much tension to pull the rotator cuff back to the articular margin right there. So we're going to be performing a cable reconstruction. So we're going to start with a long tape loaded up on a scorpion. We're going to come through our lateral portal. We're going to first go far posterior and lateral as we can. We're doing a figure of eight pass through the posterior rotator cuff I like to start posterior. And then I'll work my way from posterior to anterior. So we've already determined that in terms of the posterior anterior, if we put it back here, it wouldn't tension enough. If we put it up here it would tension it too much. So this is the spot right here that we're going for. We're going to punch down to the swivel lock or SL level. So if you notice here that we've placed this anchor where right along the articular margin here, half on, half off. And the reason why is because we want that graph to be flush with the articular margin when we're done. So now we're going to slide in here. We're going to place the anchor in there. We're going to make sure that we don't over tension it. That's just the right amount of tension that we have right here. And so we're going to go down and we're going to dunk it into the pilot hole here. So you notice here we're inserting a knotless swivel to secure that fibertape suture on the outside. You may notice here that when we pull this anchor back we're going to keep these sutures for the biologic tuboplasty. So we're not going to cut them. However we are going to cut the shorter limb of the fibertape with the fibertape cutter. We're just going to cut the short limb here. We're going to leave the long limb. So that's out of the picture now. So if you notice here we have the sutures from the knotless mechanism that we're going to later incorporate into the biologic Tuboplasty. And then here we have the long fiber tape that we're going to pull out the lateral portal. So now through the lateral portal you're going to see us every single time we're going to come in here. And we're going to pass the sutures right next to each other. So we come right here. This would be the next one. Now we apply tension every time we pass it through. Now the beauty of this technique is, since it's all going through the lateral cannula, through that lateral portal, you'll see that we don't need any special grasping tools to grab the suture each time. All we're going to do every time is just keep pulling it out the portal, and then we're just going to tension it each time. So, Chris, how much of a gap should there be between each bite of your cable reconstruction? So if you notice here we have the scorpion. Now the width of the scorpion is about four millimeters. And we want each bite to be about 3 to 5mm from each other. So if you just use this as a reference guide we can say okay, all I need to do is just move it over to right here. And then I know that is a good position for it. Good passing of the suture. So you can use the scorpion and it gives you you notice how we're about 3 to 5mm between each pass. And in terms of mediolateral, how medial do you go with your bite for the cable reconstruction. Yeah. So one of the things and again pointing out that this is a cadaveric demonstration. So we're going to get into the muscle a little bit. And that's okay for this demonstration. But when we're talking about a live patient we want to keep these passes within the tendon substance. And if you have no tendon then you just go into the muscle. Yes. Yeah. Yeah. That's exactly right. So if you notice, we've passed it several times through this lateral edge of the cuff. Now we're going to be going in for the final pass in the very front here. So we're right where we want to be placing that anchor. So I'm going to come down here. And this is going to be the final pass. Come back. And so now you can see that we are all the way from posterior all the way to anterior passing again about 3 to 5mm between each pass. And we tensioned every time we passed it through that lateral edge of the rotator cuff. Now, what we want to do is take that kingfisher again and we want to say, okay, where do we want to place this anterior anchor. So right here again we want to be looking at this to find the ideal placement. I think in this case it's going to lay right there. That's we want to place the anchor right there and again right along the articular margin. Because we know we're going to be performing a biologic tuboplasty afterwards. So we want that half on half off, just teetering right on the edge of that articular margin. So now what we're going to do is pull the suture out of the portal that we are going to be placing the anchor. So we're going to grab it, pull it right out of here. And then we're going to insert the punch back in here through this anteriolateral portal. And that articular margin half on, half off placing the anchor. And they're going down to the swivel lock or the SL level. Secure this knotless swivel lock anchor in the anterior aspect of the articular margin to complete the cable reconstruction, or to make sure that we're all the way down. Maybe just another half a turn to make sure that we're all the way down. And again, we're going to keep those sutures for the biologic tuboplasty. Now, what I'm going to do is cut the tape that we just passed. Now we're looking through the lateral portal and you can see the cable reconstruction. You can see that suspension bridge that was created with both the posterior and anterior attachments. And then again we have the sutures from the knotless mechanism for when we want to incorporate a biologic tuboplasty into this surgery. After the cable reconstruction with internal external rotation, the rotator cuff is moving as a unit. Now that we've completed the cable reconstruction, Misty is now going to demonstrate the biologic tuboplasty. So for the biologic tuboplasty, we'll switch out the lateral passport cannula from the eight to the 12. For better suture management. We'll insert a passport divider into our passport cannula. We've measured our distance between our anchors. So between our posterior anchor here and our anterior anchor. And we've measured that to be 25mm. The graft will stretch by approximately 10 to 20%. So we'll downsize our graph to 20mm in the posterior to anterior direction, and then the medial to lateral direction. We've measured 20mm. Here we have our towel here our standard blue towel that we place here on the skin where we're going to rest our graft. So in terms of orientation of our graft we place it on our towel. And in our medial aspect of our graph, we have the loop stitch on the undersurface of the graft on both sides. So that will be posterior and anterior. And then we have our two luggage tags on the lateral aspect of the graft placed in each corner. So Misty, how do you decide what graft thickness to choose? Well, typically, Chris, I use a 3 millimeter or 4 millimeter graft that's pre-cut for the biologic tuboplasty. The next thing we do is we're going to get our graft and convert it into our anchors. We'll grab the repair in the round together, and now we'll shuttle our repair stitch through our graft. There we are. And then now we will convert it through the anchor after the shuttle. Now we'll proceed to the anterior aspect of the graft and we'll do the same thing. We'll grab our round and repair, and then we'll pass our repair stitch through the graft with our previously passed links. And then we convert the repair stitch through the anchor. And there we have it. So now we have our repair stitches nicely placed. So we have some gentle tension on our lateral sutures. So now we're ready to pass our graph through the passport with a little lateral tension as we said. And immediately we're just going to kind of ratchet this in with back and forth, back and forth ratcheting that in. And sometimes we'll just squeeze this into the cannula a little bit, help it along as that's flowing in nicely through the cannula. And again keeping our gentle lateral tension as we're going through. And there's our graft. All right. Pretty good there. So at this point in time do you cut these repair sutures or do you leave them? Chris I'd actually like to keep those in because I want to be able to retension this after we do our lateral fixation. So we'll take our posterior anchor. We'll bring our lateral stitch outside. And you can see that the graph is going to lay down nicely. It's basically going to lay down right there. So we have our self punching swivel lock in place laterally with our suture. And we're going to find our spot to place our graph. Laterally we'll cut our remaining sutures here. And then we'll switch over to the anterior aspect. Here's the lateral view of our completed procedure and why I like to do the cable reconstruction with the bilateral tuboplasty is because I want to preserve as much as possible the kinematics of the rotator cuff with the cable reconstruction, and get the benefits of the pain relief of the biologic tuboplasty.

Posterosuperior Rotator Cuff Tears: Rotator Cable Reconstruction With Biologic Tuberoplasty

Asheesh Bedi, MD (Ann Arbor, MI), demonstrates a comprehensive cam resection of the femoral neck using the Hip DiamondCut™ burr.

Femoral Neck Cam Resection Using the Hip DiamondCut™ Burr

Today, I wanted to feature two great products that you have as part of your armamentarium for hip arthroscopy and preservation surgery from Arthrex. And that's the four and the 5.0mm diamond cut burs. So here's a close up. Some of the huge advantages here is its ability to work as a finishing bur. It can function well on hard bone or soft bone with great control and precision, and it avoids skipping, which is sometimes what happens on those harder surfaces with a fluted bur. It works reliably in both forward and reverse. Another advantage over fluted technology is sometimes the ability for it to protect and not wrap soft tissue in the capsule, which is at a premium during hip arthroscopy. All right. So now we have this more focused view. And just to orient everyone this is a right hip. We've completed our central compartment work as you can see here. Nice labral repair using the knotless fiber tack anchors getting a good suction seal of that labrum. And now we're just working to our peripheral compartment. There's our acetabular sided capsular limb and the rectus. And here's our femoral capsule here. And we can now start to demarcate for our camera section. Generally speaking for me I like to start superolaterally here right adjacent to the labrum. And here with this diamond burr, we can set a margin. But again, one of the advantages here is this nice demarcation and control even on hard bone in a young patient where we can set an edge and you can see it doesn't skip. I tend to use the labrum as a guide to set that physeal scar. And here I'm just going to work to define that margin of our proximal resection. You can work fairly closely here to the acetabular edge here. And again based on the position of flexion you have, you can set that margin rather nicely here. Here as we go a little bit more anteriorly I come a little further away from the labrum to set that normal angle of the physeal scar. As you can see that defines that nice proximal edge. And we know that everything proximal to that we're going to designate an important weight bearing cartilage. I'll sort of deliberately here, as you can see come in close proximity to this femoral sided capsule. And you can see not only does the hood protect us, but this diamond surface is not wrapping up that capsule as I work in close proximity, which is more likely to occur with your fluid at burs. From there, we can continue to work our camera section here. I can switch deliberately here from reverse to forward, no difference in its efficiency in resecting and setting that margin for our camera section working here from proximal to distal along the edge. We'll continue to work here. You can see here nicely. We can work right next to that labrum with good control. I'm basically abutting the labrum here laterally and can continue to work right around the corner here, even superolaterally up near our retinacular vessels. Here we can change our view a little bit. We'll rotate our eyes. You can see here we can work more medially. Oftentimes this bone here medially is a little bit softer. And this is where the fluidic bur can sometimes gouge or resect particularly in softer bone. But here our diamond burr has excellent control as we continue that resection working from proximal to distal right here towards our capsule. As you see here as I'm resecting bone, one huge advantage is we're not getting the snowstorm effect or the snow globe effect, which can sometimes obscure your view. I'm modulating the suction here, but I have an excellent view and control the entire time. And that polish and design of that diamond burr surface has specifically been designed to minimize the risk of that snow globe effect. You can see here we're working in the camera section from proximal to distal. And I can continue to work my way distally preserving this proximal convexity and then working distally here now to a more concave resection. At this point as I'm continuing to push the capsule away, I think you can see nicely even without changing the leg flexion. I'm not wrapping up the capsule at all. As we continue that resection medially and distally. Just for a moment, I'll show the view. Here you can see where we've defined that proximal margin of resection. Nice margin. And we can continue to work distally here. So as you can see we've continuing our cam resection. We've set our proximal margin. This actually is a pretty good view as you can see here of the Cam lesion. This loss of offset here and asphericity here. As we move over that direction you can even see your superolateral extent of the Cam lesion. Those are your perfusing retinacular vessels there. For the sake of this video, we've deliberately done a little mini T here so that we can see and visualize this camera section to show the value of this burr, But here I can work with great precision and even drive here up in superolaterally work right next to the labrum with great safety. Here I'm going to continue that resection proximally. And here we can work right up and next to the retinacular vessels here and actually remove that bone without worrying about winding up those vessels, even those anterior perfusing vessels. Then here, as we work our way back, I can set another margin here of resection. Again. Good control. It doesn't skip. Finishes medially and laterally with precision. And we'll continue to define that cam lesion so that we don't stop proximally. But we restore that offset here distally all the way along the head and neck junction as well. You can see it works very well working from proximal to distal. And we'll continue to work distally right here towards the distal neck. So we feel like we've restored normal sphericity and offset in all of these different planes. I'll deliberately here bring the the bur as I wouldn't right up on the capsule here deliberately try to wrap up the capsule with the bur. And if you notice it's avoiding that wrap up even when I'm intentionally trying to go towards and blur the soft tissue. It just won't wrap up the tissue the way a fluted burr does. So truly an inherent additional layer of protection to protect the capsule for your later closure. So, as you can see here, as we've progressed through our camera section, we've got a nice proximal demarcated margin for the weight bearing cartilage. We've restored offset and sphericity here in the area of the typical Cam deformity. We've had a great control here with this diamond burr. You can polish out any areas as you're inspecting around to make sure that you've been thorough in all planes. You can actually see a little impingement cyst here that we have great control over to make sure that we've gone to the right depth there. So this is a nice and thorough camera section that's well controlled using this diamond Burr technology that allows us to do an excellent pincer resection proximally and an excellent cam resection distally. Now, as you can see, because we've preserved our capsule so nicely, we can just come here and nicely repair this mini T side to side working from here to here. And then we still have our proximal capsular flap for our inner portal closure.

Femoral Neck Cam Resection Using the Hip DiamondCut™ Burr

Steven J. Lee, MD (New York, NY), demonstrates the use of the lateral biplanar plate from the Arthrex Elbow Plating System. The plate provides direct lateral fixation on the epicondyle and posterolateral fixation along the shaft, and a removable tab facilitates capitellum fixation. Dr. Lee uses the lateral positioner from the ElbowLOC® arm positioning system.

Distal Humerus Fracture Fixation With the Arthrex Distal Humerus Lateral Biplanar Plate

Hi, I'm Steven Lee from Lenox Hill Hospital in New York City. I'm going to talk about arthrex cool new contoured plates for the distal humerus. And this particular plate is the Biplanar lateral plate system. A couple of cool features about these plates is the one, of course, the anatomic contouring of the plate to the bone, but also the addition of special different tabs that are added to the distal aspect of the plate, which allows for more screw fixation abilities, especially for those hard to treat distal humerus comminuted fractures. Each one of these screw holes can take either a 2.7 or 3.5 locking screw, and the crew lock screws are a variable pitch locking screw, so it gives some mild compression and at the same time can also lock into the plate at the same time. A couple more features that I really like about this plate are that the distal end of the plate has scallops to it, which allows us to bend the plate a little bit more easily to help contour it, just in case it doesn't perfectly fit the bone. There are also suture holes to allow for you to put sutures to repair your ligament and or tendon, and you can also add suture underneath the tab as well. Some of the features that I really love about this set are that it's been very well thought out, especially the instrumentation. So there's a bunch of different reduction clamps that you're probably used to using, but also this one reduction clamp called the tooth choker. Especially like this because of the fact that it has sharp ends on the on the tip, sort of like your pointed reduction clamps, and yet is not bowed out so that when you are dealing with fractures and trying to reduce them, the Kocher clamp tooth choker would will hug the bone and it doesn't get caught up in soft tissue or the nerve here or whatever. And so it holds things very, very nicely. There are instrumentation, thoughtful features for which there are each. Most of the instruments are double sided. So I do like to use different sized freezer freezers. So there's a wide area on one side that you can use to help scrape the soft tissue off. It's appropriately sharp and soft and dull enough, and then you can flip it around and use the smaller end or the thinner end for your regular, freer application. Same thing for the other cool tool, which is the curette on one side, and the dental toothpick for reducing your fractures at the same time. And it's wonderfully balanced. You can spin it in your in your hands very easily. Also the screws in the set are all stadium seating screws, which means that they don't need to be measured by your surgical tech. Only if it sits flush on the set, then that only that screw can fit in there. So they don't. You don't have to wait for each screw to be measured, which is a very time saving feature. Often we'll put in a tack first, and I'm going to go ahead and put in my first screw in the oblong hole. This is going to be a 3.5 screw cortical screw. So that's going to be a 22. So this does come with a torque limiter. And of course to if you want to go ahead and tighten by hand as well. So I'm going to put in a 2.7 non-locking screw in distally. Again you can put either locking or non-locking screw in each one of these holes. This is a variable angle locking drill guide. So it does give you a 24 degree arc of variability. I do like reading my screw lengths directly off of the drill guide. But to note, there's two different lines on the drill. There's a single black line that you read for up to 50mm of length of the screw, and anything over that you would read off of the double black line that's on the drill. So. Hopefully you can just start seeing the double black line coming into view. So again we're going to put a non-locking screw in first. Okay. So I'm going to go ahead and put in a 2.7 non-locking screw into one of these tabs. This is a 2.7 non-locking screw going into one of the tab holes. It looks like that's conforming really nice onto the bone as well. This is our screw in locking tower guide. You can use this tower to also bend the tab. If for whatever reason, the tab is not conforming perfectly down onto the bone. So this is a 2.7 locking screw going into the tab hole distally. I'm going to put in a 2.7 distal locking screw using the screw in locking guide. So this is the distal most screw. This is going to be a 2.7mm locking screw. There is a torque limiter on the drill. This is a AP with some of our screws in. You can see the plate sits really nicely on the bone. And very importantly the screws that are put in distally are missing the olecranon fossa and providing extra fixation distally, which is my usual biggest concern with these type of injuries. This is a lateral provisional x ray. I think it looks unbelievable how well it sits on the humerus. It's very well contoured and screw positioning of where they go is optimal. This is the final AP x ray for the biplanar lateral plate. The cool thing to note here is that we have a total of five screws that are distal to the olecranon fossa, just the angle of where those screws go. Just I think are perfect. They miss the olecranon fossa and gives us extra fixation for those really difficult distal humerus comminuted fractures. So very happy with the way that looks on the bone. This is the final lateral x ray for the biplanar lateral plate. Again getting five separate screws distal to the olecranon fossa is absolutely amazing. The plate is very skinny. It's low profile, it's smoothened on the ends and the ability to take both locking and non-locking screws either 2.7 or 3.5 and any of the holes gives us so much flexibility on treating what is often very difficult fractures to treat.

Distal Humerus Fracture Fixation With the Arthrex Distal Humerus Lateral Biplanar Plate

James McWilliam, MD, (White Plains, NY), demonstrates the correction of a type III tailor’s bunion, characterized by a widened 4th-5th intermetatarsal angle, using a more proximal osteotomy on the 5th metatarsal, access at the 5th metatarsal styloid, and fixation with a bevel screw. This approach allows for a greater reduction of the intermetatarsal angle while providing a large surface area for fixation.

Minimally Invasive Correction of a Type 3 Tailor’s Bunion Using a Beveled Screw

Hello, I'm Jim McWilliam from White Plains, New York, and I'm going to talk about minimally invasive surgery on the foot with regards to bunion deformity. So if there's a large intermetatarsal four five angle or if there's significant lateral bowing of the fifth metatarsal, you might want to perform your correction via a more proximal osteotomy. And I'll show you how that's done. And I'll show you an alternative fixation method. Now here we've marked the trajectory of the fifth metatarsal in both the lateral plane and the AP plane. And I'm going to use that sort of as a rough guide for where I'm going to do my fixation. So this is going to be the trajectory of my screw. You can see that instead of being in the high and inside position of a traditional Jones screw, it's going to be going right through the fifth metatarsal Styloid. And I'm going to make my osteotomy where the wire crosses the medial cortex of the fifth metatarsal. So my osteotomy is going to be roughly here more proximal. I might even shift it a little more proximal in that x ray that. So right about there, before the watershed zone of a zone three proximal fifth metatarsal. But we're going to be proximal enough that we're going to get a good level of correction. All right. So we're going to make our incision. I will typically make the incision directly lateral. And that will kind of allow me to do a long oblique osteotomy. I'll use my little elevator. Remember this has the ideal curve to minimally elevate the periosteum dorsally and planoly. To kind of minimize soft tissue disruption but allow enough exposure. All right. So once again I'm going to go straight across just like I have with the other osteotomy. All right. X ray. So I've gone across the I've gone across the entirety of the bone. Now remember there's a declination of the fifth metatarsal. So if I just rotate my hand approximately, I'm going to be cutting distally. And the dorsal cortex. Then I've gone through there. Now, similarly, if I rotate my hand approximately and maybe direct it down just a little bit, I'm going to be cutting approximately. And the planter cortex, you can see I've got my shift there. So this guidewire is a little bit easier to work with. It's the 1.6mm guidewire for the four millimeter beveled screw. And because it's 1.6mm, it's going to be a lot easier to get my direction that I want. So I'm literally starting at the fifth metatarsal Styloid. And I'm going to drive it into the osteotomy line, kind of ideally hugging that medial cortex when I get to the osteotomy. And then we'll check on the lateral and make sure we're in the appropriate orientation there as well. We're pretty good there. So now it's simply going to be a function of moving the metatarsal over and driving the guidewire across the osteotomy and an intramedullary position. So I've got my metatarsal shifted. I've got my guidewire in the right position. So now we're just going to drive the guidewire across. You see how just putting the guidewire in this trajectory across the osteotomy site actually forces the fifth metatarsal medially, affecting your correction. So we've got good correction. We've got good position of the wire in this plane. Let's check the lateral. We've got good correction. You can see I actually cracked the dorsal cortex a little bit with my osteotomy. But we should get good adequate fixation distally without any problem. So now I'm going to use this wire as a guide for my incision. And it just minimizes trauma to the skin and it enhances cosmesis. So I'm going to take the back end of the blade and just push it down. This is an 11 blade. I'm just going to push it down along the guidewire to the fifth metatarsal. So I'm good there. Now we'll take our measuring device. It's beveled to allow us to more closely measure the appropriate depth. We're going to check that the bevel is facing in the right direction. And everything's lined up well. And we still have maintained our medial shift of the distal metatarsal. I'm going to drive this wire out the tip because not only is it our guide for the screw, but it's our provisional fixation and it's just not worth having to do everything over again. We're going to drill over this under fluoro. Not necessarily wanting to go through the medial cortex. All right. We're pretty good there. So if we line up the laser line on the drill with the laser line on the screw, we know what side the bevel is going to be on. Once the screw is buried in the soft tissue, it's just a little visual guide. It only works as long as you keep the driver engaged on the screw. So once the driver is no longer engaged, you're going to have to do it with fluoro. So there's our final fixation our final correction in the AP plane. And there's the lateral.

Minimally Invasive Correction of a Type 3 Tailor’s Bunion Using a Beveled Screw

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

During Spine Evolutions, Wade K. Jensen, MD (Afton, Wyoming), reviews surgical tips and targeting techniques for the transforaminal approach to endoscopic discectomy.

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Surgical Technique and Tips for Endoscopic Transforaminal Approach During Discectomy

OrthoPedia: Surgical Technique and Tips for Endoscopic Transforaminal Approach During Discectomy

Misty Suri, MD (New Orleans, LA), presents a case of rotator cable reinforcement with biologic tuberoplasty for the treatment of a massive irreparable rotator cuff tear in a 72-year-old male. Dr. Suri discusses his patient selection criteria, simplified technique for combined rotator cable reinforcement and biologic tuberoplasty, accelerated postoperative rehab protocol, and perceived benefits of this procedure.

Biologic Tuberoplasty With Cable Reinforcement for Massive Irreparable Rotator Cuff Tears

Hi, I'm doctor Misty Suri from New Orleans, Louisiana. I'm very excited to share a case with you of a massive, irreparable rotator cuff tear that I treated with a biologic tuboplasty combined with a cable reinforcement. So our patient is a 72 year old, retired, right hand dominant male. He fell while playing catch with his grandson. He fell on his outstretched arm and his pain was worse at night with attempted forward head activities. He had pain and he wasn't getting better with conservative management. His prior medical history was diabetes, glaucoma and hypertension. His range of motion was pretty good. He did have painful forward elevation. His subscap was intact. His strength was four out of five to his supraspinatus and infraspinatus. His AC joint was tender and his Vas score was 5.5 out of ten, and his pain score was 20 out of 100 on x ray. He did not have significant glenohumeral arthritis. He was a Hamada type one. On our coronal cuts for the MRI, we can see the significant atrophy to the rotator cuff. This would not be amenable to a rotator cuff repair. On our sagittal view here we can see the positive tangent sign with the significant atrophy to the rotator cuff as well. So what are the options for this type of patient? Debridement. Partial repair. Subacromial. Spacer. Superior capsular reconstruction var biologic Tuboplasty plus cable reinforcement or a reverse shoulder arthroplasty due to the patient's preserved joint space. For me, the procedure of choice would be biologic tuboplasty plus cable reinforcement. Combining the biologic Tuboplasty with cable reinforcement allows mean coverage of the greater tuberosity with a cushion, thereby preventing bone to bone contact, and also reinforcing the cable insertion points has been shown to improve shoulder biomechanics. Let's take a quick look at the surgical steps for this technique. Here we are viewing from the posterior portal with our grasper from the lateral portal pulling on a rotator cuff tissue. We can see the rotator cuff tissue is thin. It's friable. It's not of great quality. Not a very substantive in nature, and would be a significant risk for rotator cuff retear in the event of an attempted repair. Now we're debriding and preparing the bony bed of the greater tuberosity, and then measuring the size of the defect and graft to reinforce the cable. We'll use a two millimetres fibertape in a baseball stitch configuration moving from anterior to posterior. The appropriate tension for me is where I can place the fiber tape to exit the cuff in close proximity to the swivel lock anchor site in the greater tuberosity, to secure the fiber tapes at the anterior and posterior margins. We will use the tangible knotless swivel lock anchor. As you can see here, this is viewing from the lateral portal. This is the posterior insertion point right next to the native rotator cuff. There tensioning down that rotator cuff but not over tensioning it. Using the knotless mechanism of the swivel lock, we shuttle the four millimeter thick, pre-cut Arthur Flex graft to the prepared site, and we can see in a ratcheting type motion the graft moving nicely into the defect. Here are some other views. This is a lateral view. And now looking from the posterior aspect we can see the tuboplasty in combination with the cable reinforcement post-operatively. It's an aggressive rehab protocol. We start therapy at about one week after surgery. At three weeks. We're doing active assisted motion, and at six weeks we're doing full active motion and strengthening. And the goal is by three months to be moving the shoulder with a pain free range of motion. Here's our patient six weeks out of surgery, his Vas score has decreased to one. His pain score has increased to 40 and he's quite happy. So my experience so far is I've done 25 patients, have 12 month follow up on average for these patients, with the longest being two years out. We've had significant improvements in pain function and strength. The right patient for me in my hands is a painful shoulder that's non-arthritic non pseudo paralytic, has good range of motion with no advanced arthritis, with an intact or repairable subscap tear. In my practice, the biologic tuboplasty with cable reinforcement has enabled me to manage the challenging problem of a non-arthritic massive, irreparable rotator cuff tear with a cushion using a simple, fast and reproducible technique. As most of these procedures are performed at a surgery center, they're pre-cut. Four millimeter graft makes this a cost effective solution. Last but not least, my patients have experienced significant pain relief, allowing them to progress through my expedited rehab protocol. Thank you.

Biologic Tuberoplasty With Cable Reinforcement for Massive Irreparable Rotator Cuff Tears

Benton A. Emblom, MD (Birmingham, AL), repairs a gluteus medius tendon using a double-row tendon compression bridge.

Endoscopic Double-Row Gluteus Medius Repair Using the Gluteus Medius Repair System

I'm Benton emblem. I'm an orthopedic sports medicine surgeon in Birmingham, Alabama at Andrews Sports Medicine and Orthopedic Center. What we're going to demonstrate today is a partial thickness gluteus medius tendon repair. I see a good bit of these in middle aged women between 50 and 60 that have lateral hip pain, that often complain of discomfort for a year at least, that are treated empirically for gluteus medius tendinitis and or trochanteric bursitis. An MRI typically is obtained and shows a partial thickness gluteus medius tendon tear. These can be easily repaired endoscopically with a 30 or a 70 degree scope from the trochanteric space utilizing knotless suture anchors. We're going to demonstrate the repair of a partial thickness gluteus medius tendon tear, utilizing the 2.6 Knotless gluteus medius Tendon repair Kit. In this kit includes the drill guide and drill. The two anchors knotless 2.6mm the Millimeters the cutter. And in this instance we're going to utilize two additional anchors to create a two row or double row configuration repair. So we're established in the trochanteric space of the hip. This is a right hip proximal distal. Our two portals that we've created so far are a mid lateral portal. This is approximately four centimeters or a finger four fingerbreadths distal to the kind of the mid greater trochanter. And this is our standard anterolateral portal. So what we've done up to this point is we've prepared the trochanteric space by doing a complete bursectomy. We've identified the gluteus Maximus sling right here, which is our distal posterior landmark. And then this is our gluteus medius gluteus minimus muscle tendon complex. And this is the vastus lateralis. If you note the vastus lateralis has a very distinct sheen to it. And it's typically what I call the lighthouse of the trochanteric space. So in some in some cases of partial gluteus medius tendon tears, if the tendon length is pretty short, we'll typically do a single row knotless compression bridge construct and others where the tendon length is more substantial. We'll do a two row where we'll utilize four anchors. In that case, we'll typically develop an X footprint configuration by putting two anterior anchors and two posterior anchors. In that case, we'll take our anterior superior anchor and feed it and couple it with the posterior inferior anchor. And then once that's converted, we'll take our anterior inferior anchor here and convert it and couple it with the posterior superior anchor. So we'll put our first anchor in here. Oftentimes you have to manipulate the leg so that the trajectory of the drill is appropriate to prevent from skiving. So in this case you can notice that this drill guide is aiming somewhat tangentially to the proximal aspect of the femur. So we're going to have our have our assistant internally rotate the femur so that it'll bring the proximal femur a little bit more internally positioned. So we'll put our first anchor in right here which is going to be our anterior superior anchor. This is going to be the knotless 2.6mm FiberTak. So we're going to drill here. And when we insert this anchor we will by hand ensure that we have the anchor started into the pilot hole. And then we'll gently tap it with a mallet. So the backside of the guide will go flush with the handle of the inserter. And you just pull straight back after you've. Gotten the suture undone. And I just do a gentle pull not to try and deform the anchor, but just to make sure that we're well seated in the bone. So now we've established our are proximal posterolateral portal to insert our posterior anchors. So we've placed our most superior anterior anchor and our most inferior posterior anchor. And now we will convert these anchors creating a compression bridge configuration. So we'll take a loop grasper. And what we have to do here is we're trying to take this stitch here and take it to that anchor and that blue stitch there and bring it to this anchor. So what I like to do is I'll take the loop Grasper push the suture somewhat into the field. I'll grab the round stitch here and I'll run over. And I will basically grab the blue stitch here. And pull these out through the anterior lateral portal. And then we'll come back in through our posterior portal, grab our round stitch here and move forward. And grab our blue stitch. Carefully watching the SutureTape down here to make sure that the conversion stitch doesn't unload itself. And now we're going to convert our posterior stitch by converting it through the looped shuttle. We're finishing the conversion. We're sequentially tensioning each limb of the compression. Suturebridge. So we now have a nice tensioned bridge from anterior to posterior. And this is one limb of our x. So now we've placed our other two anchors to create the create the second limb of the X of the two row compression construct. We'll come in with our loop Grasper. And just like we did the first time, we'll grab our round suture and come posteriorly and grab our blue repair stitch. And we'll come back in our posterior portal and grab our posterior round conversion stitch. And then come to the anterior inferior anchor and grab its appropriate repair suture. And then just like in the first limb, we'll convert the knotless mechanism and convert loosely so that we don't over tension one limb of the compression bridge and then sequentially tension that creating a two row compression bridge in an X configuration. So this is our final construct. After we've converted two pairs of the 2.6 Knotless FiberTak creating a x shaped two row compression bridge. You can see here we've got our anterior superior anchor, our anterior inferior anchor with our posterior superior anchor and our posterior inferior anchor. And as our assistant externally rotates the leg, you can see as the gluteus medius minimus complex comes under tension, you can see this configuration remains taut and provides excellent compression of the partial thickness gluteus medius tendon tear.

Endoscopic Double-Row Gluteus Medius Repair Using the Gluteus Medius Repair System

Sanj Kakar, MD (Rochester, MN), shares a surgical pearl for using the NanoNeedle™ scope 2.0 to access the thumb CMC joint.

SpeedPearl: Accessing the Thumb CMC Joint With the NanoNeedle™ Scope 2.0

Speaker  Accurate diagnosis and assessment of the articular surface of the thumb CMC joint is particularly important, for example, in fractures and when managing thumb CMC arthritis. However, this joint is tight. Given its complex anatomy, and so this is perfect for the nanoneedle scope given its lightweight, small and flexible design. The Nanoneedle allows for safe entry into the thumb CMC joint. I typically create the one new portal first and to provide greater working space, the portal is created next.

SpeedPearl: Accessing the Thumb CMC Joint With the NanoNeedle™ Scope 2.0

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

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

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

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

John 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

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

At the Orthopedic Technology and Innovation Forum, John J. Christoforetti, MD (Bethesda, MD), and Benjamin G. Domb, MD (Chicago, IL), review the evolution and application of knotless all-suture anchor technology in hip arthroscopy, highlighting its advantages in reproducibility, safety, and adaptability to the anatomical constraints of the hip joint.

Femoroacetabular Impingement (FAI) and Labral Tears: Literature Review on All-Suture Anchor Outcomes in Hip Arthroscopy

OrthoPedia: Femoroacetabular Impingement (FAI) and Labral Tears: Literature Review on All-Suture Anchor Outcomes in Hip Arthroscopy

The Arthrex ElbowLOC® positioner is a modular, upper extremity positioner that gives the surgeon the choice of supine, lateral, or supine-suspended positioning for elbow surgery, as well as a wrist traction device for wrist and hand arthroscopy. The ElbowLOC positioner is easy to use and set up, and housed in a space-saving single autoclavable tray.

The Arthrex ElbowLOC® Elbow and Wrist Positioner

The Arthrex ElbowLOC® Elbow and Wrist Positioner

What's NewMAY 21

Posterosuperior Rotator Cuff Tears: Rotator Cable Reconstruction With Biologic Tuberoplasty

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Distal Humerus Fracture Fixation With the Arthrex Distal Humerus Lateral Biplanar Plate

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Minimally Invasive Correction of a Type 3 Tailor’s Bunion Using a Beveled Screw

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

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