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At the Orthopedic Technology Innovation Forum, Rachel M. Frank (Denver, CO), discusses the advantages of using the TightRope® SB implant for the treatment of ACL injuries and multiligamentous knee injuries and shares tips for implantation techniques.

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All-Suture Implant Techniques in Ligament Reconstruction

Orthopedia: All-Suture Implant Techniques in Ligament Reconstruction

The Mini Fragment System is designed to aid in the reduction and fixation of small- and long-bone trauma injuries. The modular tray offers screw and plate options in 2.0 mm, 2.4 mm, and 2.7 mm variants. With a wide array of plates to fit a multitude of trauma needs, the Mini Fragment System is a keystone addition to the Arthrex Trauma portfolio.

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Mini Fragment System Animation

Mini Fragment System Animation

The revolutionary TightRope SB™ implant eliminates metal hardware from ACL reconstruction procedures and features a suture-based button for cortical fixation. This animation demonstrates a QuadLink™ ACL reconstruction using the FiberTag® TightRope® SB implant with 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.

QuadLink™ ACL Reconstruction With the FiberTag® TightRope® SB Implant and InternalBrace™ Technique

The Quad Link SP construct features a revolutionary suture based fiber attack tightrope SB implant to treat ACL injuries without metal hardware. The fiber tagged tightrope SB implant uses a radiopaque all suture cortical button that provides improved strength with a minimally invasive, low profile design compatible with existing arthrex retro construction and tightrope drill pin socket drilling techniques. The comprehensive line of tightrope SB implants accommodates all graft types and are available with preloaded radiolucent or radiopaque fibertape suture for the internal brace technique, allowing surgeons the flexibility to leverage cutting edge tightrope technology with the graft and technique best suited to the unique needs of every patient they treat. Place the ACL femoral guide over the ACL femoral footprint arthroscopically. Adjust the angle of the guide to the desired position and tunnel trajectory, and then lock into place. Push the ratcheting drill sleeve down to bone. Advance a flip cutter three drill pin through the ACL femoral footprint. Tap the tapered portion of the drill sleeve into the femur seven millimetres or until resistance is felt when reaching the femoral cortex. Using the, we'll deploy the flip cutter three drill to the appropriate size and retrograde drill back to the sleeve to create a socket. Remove the flip cutter three. Drill and pass a blue and white fiber. Snare suture through the drill sleeve. Retrieve it from the lateral portal and dock it for later graft passage. Remove the drill sleeve. Place the ACL tibial guide over the ACL tibial footprint. Arthroscopically. Adjust the angle of the guide to the desired tunnel position and tunnel trajectory, and then lock into place. Push the ratcheting drill sleeve down to bone. Advance the flip cutter three. Drill through the ACL tibial footprint. Tap the tapered portion of the step drill sleeve into the tibia seven millimetres or until resistance is felt when reaching the tibial cortex. Using the, we'll deploy the flip cutter three drill to the appropriate size and retrograde drill back to the sleeve to create a socket. Remove the flip cutter three. Drill and pass a black and white fiber. Snare suture through the sleeve. Retrieve both the fiber. Snare sutures from the medial portal, and remove the stepped drill sleeve with the blue and white fiber. Snare suture. Pass the femoral side of the quad link. Construct into the femoral socket, keeping the white and black tiger wire suture under tension to elongate the all suture button until it flips on the femoral cortex. The fibertape internal brace, suture, or tibial tightrope loop can be pulled to confirm deployment. Use the white tensioning sutures of the tightrope SB implant to advance the quad link construct into the femoral socket. With the black and white fiber snare suture, pass the fiber snare suture for the internal brace technique. The white tightrope tensioning strands and the blue leader suture into the tibia. Maintain counter tension on the tiger wire. Suture to elongate the SB implant while shuttling the fiber. Snare suture distally. Pull on the inside of the fiber tag tightrope SB loop to advance the graft into the tibia with the knee in extension, pull on the white shortening strands to advance the soft button down to bone before tensioning the quad length. Construct. Anchor the fibertape sutures for the internal brace technique using the ACL Back-Up fixation Kit. Using the spade tip drill followed by the 5.2mm tape. Place the fibertape suture for the internal brace technique into the eyelet, and screw the 4.75mm swivel lock anchor into the drilled hole. Take the knee through range of motion before fully tensioning the quadling construct. The knee can be cycled several more times and both implants re tensioned to alleviate residual creep. The tiger wire and fiberwire sutures can be removed. The tightrope tensioning strand can be cut, flush or tied over the soft button based on surgeon preference.

QuadLink™ ACL Reconstruction With the FiberTag® TightRope® SB Implant and InternalBrace™ Technique

The PARS Achilles Midsubstance SpeedBridge™ implant system is a percutaneous, minimally invasive technique used to repair Achilles tendon ruptures. Using color-coded 1.3 mm SutureTape, the PARS system makes it easy to create a percutaneous locking stitch in the Achilles tendon, while staying inside the paratenon sheath.

Achilles Midsubstance SpeedBridge™ Surgical Technique

When using the parse jig for the Achilles mid substance SpeedBridge technique, a percutaneous incision is made in a transverse manner just proximal to the palpable rupture. Alternatively, a small longitudinal incision can be utilized. The tendon is grasped and the jig is inserted with the inner arms inside the peritoneum of the Achilles tendon. The first parse needle is placed in the number one hole in the jig to stabilize the construct, while passing the other needles and sutures in sequential order. Lastly, the white SutureTape is then passed through hole number one. The jig can then be removed, which pulls the sutures out of the incision. Separate out each of the five sutures, the white, blue, and black suture tapes, as well as the two green and white FiberLink sutures. Each suture should be tested by pulling light tension through ten cycles to confirm appropriate hold in the tissue. On both sides, past the blue SutureTape under and around both green and white. Fiberlink SutureTak twice and back through the loop, then advance each loop back through the tendon using the free end of the green and white FiberLink sutures. This creates the locking stitch. Two stab incisions are made one centimeter below the superior aspect of the posterior calcaneal tuberosity. Medial and lateral to the Achilles tendon. Within these two stab incisions, insert the guidewire utilizing the drill guide with the white centering sleeve at 45 degrees from the centerline of the Achilles in the coronal plane, and 45 degrees from posterior to anterior in the sagittal plane. Guidewire placement can be checked under fluoroscopy. These two holes are drilled with a 2.6mm drill and tapped for later SwiveLock insertion. A banana. Suturelasso is passed through the distal stump of the Achilles and out of the rupture site. The SutureTape from the proximal portion of the tendon are then passed through the distal stump and out of the stab incisions distally. The suture tapes are then loaded through the eyelet of the Rd 3.9 biocomposite SwiveLock anchors. The foot is plantar flexed 10 to 15 degrees to approximate the tendon ends. The SwiveLock anchor is placed into the prepared hole to secure the suture tapes. The laser line feature on the SwiveLock shaft can be utilized to confirm when the anchor is flush, or two millimeters countersunk. The same steps are repeated for the suture tapes on the contralateral side. The incision is closed. Jumpstart antimicrobial dressing can be utilized and the result is a secure knotless repair of the Achilles tendon rupture.

Achilles Midsubstance SpeedBridge™ Surgical Technique

Tim R. Lenters, MD (Grand Rapids, MI), highlights the latest metal segmentation feature in the Virtual Implant Positioning™ system while planning a challenging glenoid revision with significant bone loss using the Augmented Modular Glenoid System.

VIP Vision™: Episode 11—Metal Segmentation for Revision Planning

Hi, my name is Tim. I'm a shoulder surgeon in Grand Rapids, Michigan. I've been using the VIP system now for over ten years, and I'm happy to share a case presentation that highlights some new features of the planning software. The planners can now perform metal segmentation on your surgical plans for use in revision cases of existing implants. So what previously used to require potentially several surgeries, with the first surgery being removal of an existing implant to allow us to obtain a clean CT scan, that first step is no longer needed with metal segmentation features of the VIP system. I'd like to use this case to highlight some of those features on the platform. My patient is a 68 year old. She's fairly low demand female. She had a reverse total shoulder arthroplasty five years prior to her presentation with me. She describes one month of progressively worsening pain in her shoulder, and she has also had a few falls over the last year, although none of these falls led to a significant worsening of either pain or function of her shoulder. I was able to find her x rays from her early postoperative period. She has a reverse total shoulder arthroplasty with a lateralized glenoid sphere. It seems to be an appropriate position in terms of the RSA angle, as well as in relation to the inferior scapular neck or x rays. On presentation to me, show a catastrophic failure of the base plate with fracture of all three of the fixation screws, and in my mind, I felt it was essential to rule out the possibility of an indolent infection, despite her history of some falling onto the shoulder. I did do an infection workup. Her inflammatory markers were normal, including the SED rate, the CRP, and her white count. I also aspirated the shoulder to culture and the cultures did not grow. Any organisms at three weeks or vitamin D level was also checked and found to be in the low range of normal. The CT scan was also obtained and I found it somewhat challenging to observe what sort of bone was remaining into the glenoid vault on this axial cut. I can just appreciate that there's bone loss and maybe some residual bone inferiorly. The coronal image shows a fairly large defect here, and raise some concerns about my ability to utilize a standard implants for this reconstruction. I did decide to upload this image to VIP software to see if potentially, I'd be able to utilize a standard implant for this reconstruction. So at this point, I uploaded the study to VIP, and we'll go through sort of a live planning session to demonstrate the features of the system. You can see the old existing implant is green. You can see the existing screws in the vault. The planners have been able to identify those structures and highlight them with these blue outlines. The surgeon can easily toggle visualization of these features with this little window on the right side, and this will make the implant disappear. And what you see then is what's left of the scapula. And it's fairly obvious that there's a very large posterior defect in this glenoid vault, sort of an uncontained wall defect. The vault is missing. You can see there's maybe a little bit of bone remaining in the base of the coracoid process. There's a nice column of bone anteriorly and maybe some bone inferiorly. You also can see that perhaps the scapular spine is available to use asphyxiation. So in my mind at this point I had really three options. One option would be to utilize the scapular line for fixation, to try to sink the post of the base plate down the spine of the scapula. Second option in my mind was to use Grammont principles and Medialize. And inferiorly lies the sphere to try to minimize the shear along the back side of the implant. And then my third option would be to develop and manufacture some sort of a custom implant, which is my which would be my least preferred option. So my first option was to look at use of the alternate scapular plane. And if we bring that implant in, what I thought was the alternate scapular line here you can see the post is seated in the base of the scapular spine. The windows on the left side here can show you what sort of bone is available on either side of your central post, and there seemed to be a nice quarter of bone in this position. The top window gives you sort of a coronal view, and here you can start to appreciate where the glenoid might reside in relation to the inferior scapular. And I did have some concerns with the position of this implant. I was worried about this bone posterior inferiorly that the humeral cup might impinge on that bone. And so this looks like it might be an option in terms of fixation of the center post. I did have some concerns about the overall position of the glenoid in relation to this inferior glenoid neck. So I looked at another option, which would be more of a Grammont principle to digitalize and medialize the sphere. And you can see in this position, if I remove the sphere itself, the base plate seems to be seated reasonably well. I have 53% backside contact with just a non-augmented base plate. The post seems to be seated in a nice area of residual bone, both on the axial plane as well as on the coronal plane. The sphere looks to be in a better position in relation to that posterior inferior scapular neck. And so in my mind, this seemed like a very reasonable option. I did want to utilize some other features on VIP. So if we look at the range of motion module, we can see that in this position there may be some issues with impingement of the humeral cup against some remaining bone around this sphere. And so it would be useful, I think, at this point, to utilize the Osteophyte removal tool to remove some of that bone and see if we can improve the range of motion. You can use that tool from this window. So I'll go through some of those steps right now. Remove some of these potential sources of impingement. We can reassess the range of motion following this bone removal. And this is something I would do in surgery if I see sources of impingement. I'll just simply take a roger and remove some of these problem areas. But once we do that, we can reassess now the range of motion we'll bring in the humeral component one more time. There's a nice abduction. We've improved her abduction. External rotation seems to be moving more freely without impingement until 41 degrees of external rotation. Internal rotation seems free. So I thought this would be a very good reconstruction. At this point, I finalized the surgical plan by hitting the subscribe button. Prior to surgery. So the planners were able to develop a surgical plan. These images show the 3D targeter on the patient's scapula, and you can see we could get four of the peripheral legs to seat very nicely, with the standard two legs wrapping around the front rim and the two other feet sitting on the face of the existing glenoid bone. And I was surprised, somewhat surprised to see how well this transfer technology worked in the patient, and how well the surgical plan mimicked the actual anatomy that was encountered at the time of surgery. At the time of revision, I did use some bone croutons to graft some cavitary defects from the screw tracks. I did not encounter any evidence of a chronic infection. There was no biofilm. There was no Seroma noted. I did take five sets of tissue cultures, understanding that this might represent a chronic infection, but I felt I was able to achieve a durable reconstruction that mimicked my surgical plan very nicely. You can tell that based on the overall position and fairly with a little bit of overhang of the sphere in relation to the neck. I think the center post nicely aligns with the floor of the suprascapular fossa, and I like my position on the anterior posterior plane as well, with the sphere sort of covering that posterior glenoid rim. So at latest follow up the patient shows a stable reconstruction with improving clinical metrics. I do believe that the newest capabilities of the VIP system allowed me to plan this case, and feel comfortable with the use of standard implants. Vip turned what could have been a challenging and uncomfortable situation into a definable problem with a definitive solution. I encourage you to make use of this system if you see failed shoulder implants. I believe it will help you plan your surgical plans and optimize your patient outcomes. Thank you for allowing me to present this case.

VIP Vision™: Episode 11—Metal Segmentation for Revision Planning

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

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

During Spine Evolutions, Prof. Dr. med Mazda Farshad (Zurich, Switzerland) presents a literature-based discussion on irrigation management during spinal endoscopy.

Endoscopic Spine Surgery: Irrigation Insights

Orthopedia: Endoscopic Spine Surgery: Irrigation Insights

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

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

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

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

Rachel M. Frank, MD (Denver, CO), shares three pearls for simplifying extra-articular tenodesis procedures.

SpeedPearl: Simplifying Lateral Extra-Articular Tenodesis

When performing lateral extra articular tenodesis, I found that these three pearls make the procedure reproducible and reliable. Number one place the incision where you anticipate the anchor will go. This allows you to keep the incision small. Number two place the anchor exactly where it needs to go from an isometric perspective. Posterior and proximal to the lateral epicondyle. Number three trajectory. Aim your drill guide anterior and proximal to avoid convergence with the ACL femoral tunnel.

SpeedPearl: Simplifying Lateral Extra-Articular Tenodesis

Ryan B. Rigby, DPM (Logan, UT), demonstrates using the NanoNeedle Scope and instrumentation portfolio for ankle arthroscopy.

NanoNeedle Scope for Ankle Arthroscopy

All right. Well we're going to insert and show you a little bit on the inside of the joint. Before we do, let me highlight just some portal placements. For my placements I always use a distractor for most of these cases. But on that note, if it's a trauma case, you're not wanting to do all of that. Again, the ease of just putting this in with a needle and not having to do all the setup of a distractor is is again, one benefit to using the nano needle. If I'm doing, say it's an ankle stabilization, I want to scope. We'll use that as a situation today. I do always outline the medial malleolus, the inferior border here. This is the tibialis anterior tendon. You can feel the edge kind of that medial edge. And about a finger width up I make a medial anteromedial portal angling back into the joint. Here it's a nice safe spot, angling towards the fibula. As I insert instruments to establish that first portal, I always start on the anterior medial. I've outlined the superficial peroneal nerve here. We want to avoid that throughout the entirety of our of our procedure anterolateral portal as well. Just being able to instrument and do some work. If you need to reach further for other spurs, you can come even further lateral as well. So there's portal placement. We'll move forward. We're using the high flow sheath. We'll remove this and insert our nano needle. It does kind of click into position. We'll turn on our fluid and we'll look around a little bit and show you guys a couple things here. We'll switch over to the inside of the joint here. Okay. So basically you can see just first off we're inside the ankle joint. But how quickly I can get to the back. Whereas normally that's harder to do. The smaller 2.7 scopes bottom out. And the larger forces sometimes can't fit in here. But I'm easily all the way to the very back of the tibiotalar joint. So you can see the difference in having such a smaller instrument. And also you get a feel of that wide view and just straight on and not looking around the corners with this. So okay, so we're looking at the tibia above, the talus below. We're inserting in our our nano shaver. And we do have a little bit of some synovitis I scope every ankle stabilization because they typically nearly 100% of the time will have synovitis. So we'll work some of this out and you can see the picture quality. I mean, this is cool technology, especially being such a tiny little scope to have that kind of quality here and the ease of just using this on the iPad, if I want to, I can turn the the microphone on and tell the patient, this is all the scar tissue and inflammation that you've developed over years of spraining your ankle and just work around. And you can see, even though this this little saber shaver is a small shaver, it's still very aggressive and and works nicely. And I'll, we'll use it to show some diagnostic purposes or value of it as well here. So I just wanted to show you I left all the all the synovitis when we first entered the joint, so that I could show you just how quickly and easily that works. I do love how smooth it is in entering the joint without these teeth that will will scar the cartilage so smaller, smoother, but still aggressive and great suction. You know, one thing while we're here is just coming back. You can see how we can work towards the back of the joint, clearing out any synovitis or herniation of the syndesmosis. One thing I think we all should be documenting, based on the papers that we have now, is the syndesmosis, especially in the setting of ankle instability. And so based on several papers, one being Guyton's paper, which talks about the ability to insert a three millimeter probe into the syndesmosis would be indicative that you now have global instability laterally, medially with the deltoid and the syndesmosis. And so I always just come up and say, okay, can I insert instruments into the syndesmosis on this patient? It's negative. And I would document that in the OP report and say the syndesmosis appeared intact, I could not insert my shaver into the syndesmosis. Arthrex also has probes that come at various sizes that you can use to put in there as well, and you'll be surprised if you do that every once in a while. You'll run into one where I did not realize, hey, they have some syndesmotic instability and you can slip that shaver up in between the tibia and fibula, and you should be placing TightRope or an anterior TfL internal brace. I'll also come to the front of the fibula here and just push on it from front to back, and you can see that Syndesmosis is nice and tight there. If that was unstable, you'd be able to see a little anterior to posterior translation, but also just highlighting again the saber shaver, how I can get up into these little tight areas and just kind of clean some of this stuff out here. So there you go. That's that's the arthroscopy portion of, of this demonstration. Let me switch the portals and we'll talk just a minute, a little bit further about something I'm excited about when it comes to ankle stabilization and making decisions on which ligaments need to be, which need to be repaired. Just. And you and I have had several conversations and conversations and working on projects together. So I've switched the portals. I usually for me, I do like to have the the flat part basically facing up towards the tibia or the patient's head, and that gets me oriented on the camera. So I know that I'm looking up at the tibia. It just helps me keep orientation within the joint. Switching portals here. Come around to the medial side, get our shaver in. Still a little bit of some synovitis that we can work on. Let me clean that up a little bit further and then, you know, let's talk a bit about the deltoid. I've got some data that I'm about to it's actually been submitted for publication, finding the incidence of the deltoid being involved in ankle instability. And we're finding it's 20 to 30%, which is a lot higher than I previously was repairing. So we're working on techniques to diagnose basically identify when that actually needs to be repaired. And in the trauma world, they've called it a drive through sign. And in the acute setting, that's, I think, still very applicable and appropriate. And what that looks like is if you come over here to the medial gutter and you take a shaver, I usually, you know, in an ankle scope, we'll use even up to a four millimeter shaver. But you can come over and you can peek around the corner and you can look down at the deltoid and see if it's torn, or do this drive through sign in in the medial gutter. And if your shaver fits in between, if you can, take and insert it here, just as we've done down in between there. And it fits quite easily. And so just to give you a heads up, I did release a good portion of the deltoid just in preparation so I could show you this maneuver. But this and this is a smaller shaver, but as you can see, that fits. So if I have a four millimeter shaver and that fits in there, we know that that deltoid is a little bit incompetent. There's a little bit of some subtle instability. Maybe it's not gross instability with severe valgus tilting, but there's a little more global instability from medially to laterally. So that's the drive through sign. You'll see papers starting to come out. We have data we're publishing on this. We actually validated this in the lab in the last couple of months. But this is the medial drive through sign. And even you can sometimes just take the shaver and even just push and see the medial side open up at times. So I wanted to highlight that as well. Some of the diagnostic things. If you're not scoping your ankle stabilizations, you're missing out on a lot of pathology, and there's nothing worse than having a nice stable ankle that still hurts from all the synovitis still in there. Document the syndesmosis that it's intact and stable. You can document, of course, osteochondral defects, frequent things we encounter in ankle instability. And then the deltoid. Was the drive through sign negative or was it positive? And if it is I encourage you to go. We use a couple of FiberTaks typically here. The new knotless FiberTaks work well to do a medial deltoid repair.

NanoNeedle Scope for Ankle Arthroscopy

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

The DualCompression hindfoot fusion nail creates a stable fusion site by providing two modes of compression for intraoperative and postoperative dynamic compression across both joints.

DualCompression Hindfoot Fusion Nail Demonstration

The Arthrex dual compression Hindfoot nail mechanism demonstration with a distal calcaneal screw and the distal tibial screw already inserted. The t-handle is attached to begin tensioning the dual compression mechanism. As the cable is tensioned, it pulls the dual mechanism slider distally until the joint is fully compressed. When the joints can no longer compress, the nitinol element begins to stretch and continues to stretch until the distal slider reaches its final position in the distal slot hears the compression sequence again in slow motion. Once it has been fully seated, the second posterior to anterior calcaneal screw is inserted to lock the distal slider in position and maintain the compression across the joint. An optional Taylor screw is then inserted to provide rotational stability of the talus. An optional second proximal tibial screw can be inserted for additional support proximally.

DualCompression Hindfoot Fusion Nail Demonstration

John Xerogeanes, MD (Atlanta, GA), demonstrates how to use reusable sliding GraftClamp instruments with the GraftPro® system during a quad tendon ACL reconstruction using FiberTag® TightRope® SB implants. The reusable GraftClamp instruments simplify graft preparation by allowing single-user graft preparation.

Quad Tendon Graft Preparation Using Sliding GraftClamp Instruments

We're going to take you through what we have on the table today. We have our standard Graph Pro, we have our fiber tag tightropes, these being ones with soft buttons. We have our our graph sizing tubes. We have our tenaculum scissors a graph. And then we have our new graph clamps. One of the downsides when you're preparing a graph is especially on a quad tendon, you need an assistant. We've tried to eliminate the need for an assistant, because you don't always have that extra person in the operating room. These are the new graft holding clamps, which eliminate the need for an assistant. You can see they look like a normal clamp just would come down. You can make it tight, but they have a sliding feature on the back. This hooks on and slides back and forth. What this allows you to do is pass a looped graph without pulling this out, or not having or allowing your assistant to pull it around the graft. So there's two types. This is the part for we used to hold the graft. And this is a part that we use to hold the card on the graph. This one is just like a normal tenaculum. And I'm going to grab the normal tenaculum that you see. And you see this one that has a little slot right here for the card, and you can hold your graft. And this is the one your assistant used to hold. Now we're going to eliminate your assistant and use the card here. Hold the graft. And then this will be under tension to hold the graft tight while you make it. So to put this on, you go 90 degrees, hook it and then you're you're you're hooked. You can see where the arrow is, which tells you which direction you're pulling and you slide over. And in that slot you can move your suture. So we've just harvested our quad tendon graft. You have the loop suture that we used on the distal portion of the graft to pull it through the Quad Pro, and when we prepare the graft, we always want to prepare the tibial side first. And that's always the proximal portion of the graft. Because this is the most severe part of the graph that you have to tubularize. And it's the most inconsistent. So the first thing we need to do is stabilize the graft and hook it to the back part. And now we have the graft hooked nicely. I often will come back here and cut this. So we keep these extra sutures out of the way. So now we'll take both posts and place them in the graft pro. You can see the arrows at the top here telling you which direction that the tension is going to go between these two. And now what we have to do is take this graft and put the the fiber tag tightrope on. So we'll grab the tibial side. We unwind this from the card. And just like we used to use the tenaculum, we're now going to use our tenaculum clamp. And again here it slides in. You can see it holds it perfectly. So put that in the middle. And you find your distal end of your fiber tag and you pop it through. So just like you would a tenaculum clamp. Now we take our graft, put the distal part in, we pinch it and slide it down. Now that we have our graft loaded onto the clamps, it can easily be transferred to the Graph Pro. Remember, you have to come in at 90 degree angle to get the clamp on. So leave a little bit of wiggle room here that you can go in. And now that we have it set we can put tension on here and we're ready to go. Usually when you're preparing a graft, your assistants are pulling tension on the part with the card on it. When you do that, the assistants often across from you. So we find it easier to change the angle of your graft pro so it holds it like this. All right. So now we're going to put the fiber tag on the proximal end of the graft. As you know the fiber tag has many advantages. The greatest advantage is its cyclic strength is incredible. So you don't get cyclic deformation like you do on regular sutures. Secondly, it's a much faster way of preparing the graft with less suture load. So we hold a little, we hold tension. And again I don't need an assistant holding tension I come right through. I hold my finger on the fiber tag and I pull this so it's nice and flat. Okay, now I slide back this way and again. Many times you would you would have to lift this out and go underneath to pass the suture loop. We don't have to do that anymore. All we do is pull up underneath, slide over and come out. And now this is ready to put my next suture in so you can see it's much faster. You save time and you don't need an assistant. So I'll show you that one more time. We pull tight. We separate. We come underneath. We use the suture to pull over. We come out and now we're ready to do our next throw. Now we're ready to lock the fiber tag. Tightrope construct in place. So we come underneath through the hole, and then we come down right next to that point. And again you see the tension that this holds for us. So it makes it very easy for us to pull tension. Now you could also pass from the opposite side. So if you're left handed it's often easier to pass from left to right. Then you can use your your left hand to put the needle through the tendon. So in this case again you pull up and under you slide across, you come out and you're ready to place your last piercing. So we go through, we come down, we tubularize the graft. Now, when we. If we want to come back, if you're ambidextrous, you can come back, go up and over, and then you don't have to slide things back and forth. And now we tie the sutures. Now, this is a very flat, lying suture. Some people like to bury the knot. I tend not to, because I think it's just not very big. So we get a nice flat knot. And then we cut the end and we're good to go. So now that we've prepared one end of the graft, you can take the tenaculum clamp off and use it to hold the other end of the graft. We secure this with the traditional alligator type clamp. Be careful that the clamp itself grabs only the card and not the sutures between the card. You don't want to damage any of the sutures, so grab the card itself. So now we're going to prepare the femoral side of the graft in a similar fashion that we did the other side, we hold tension on the fiber tag we come down through. And we get this place nice and flat. So now that we place the fiber tag, we have two options on how we want to pass the sutures. We can pass closest to us like you saw on this end of the graft, or we can pass away from us. So to pass away from us, we pull under the graft. We slide the suture Over. We push over. And we're ready to pass. Now, you saw one of the reasons why I don't love it this way. Because it can get caught on the card. But you have personal preference. And if you choose to pass it that way, it will work on either side of the graft. And again, I'll show you one more time. So again, if we go proximal, if we go to the top part of the graft, we come in, we hold over and we come underneath. And if you pull tension on the graft, you're able to avoid grabbing the card. So again, it works either way. It just has to do with personal preference. So now we're ready to tie. We take the needle off the graft suture and we're going to. Again put a nice flat. Not here. And this suture ties very flat. So it's not bulky at all. Again make sure you're tying a square knot here. And then your graft is ready to put in the graft tube and place in the patient. We prepared this graft just like an assistant was helping me. Some people feel more comfortable with the graft perpendicular to them. And you can certainly do it this way, because, again, you don't need an assistant holding a graft off to the side. It's again your personal preference.

Quad Tendon Graft Preparation Using Sliding GraftClamp Instruments

At the Complex and Revision Shoulder Arthroplasty Surgery course, Brian C. Werner, MD (Charlottesville, VA), discusses the rationale for using the Virtual Implant Positioning™ (VIP™) system for preoperative surgical planning for total shoulder arthroplasty cases.

Taking Advantage of Preoperative Planning for Total Shoulder Arthroplasty

OrthoPedia: Taking Advantage of Preoperative Planning for Total Shoulder Arthroplasty

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Orthopedia: All-Suture Implant Techniques in Ligament Reconstruction

What’s New This Week and Prior

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Mini Fragment System Animation

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QuadLink™ ACL Reconstruction With the FiberTag® TightRope® SB Implant and InternalBrace™ Technique

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Achilles Midsubstance SpeedBridge™ Surgical Technique

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VIP Vision™: Episode 11—Metal Segmentation for Revision Planning

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