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

Hand and Wrist

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Peripheral Nerve Injuries: General Surgical Considerations

OrthoPedia: Peripheral Nerve Injuries: General Surgical Considerations

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

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

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

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

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

Knee

MPFL Reconstruction With the RT TightRope® SB Implant

MPFL Reconstruction With the RT TightRope® SB Implant

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

Subscapularis Tears Presentation Series (Part 2): Outcomes

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

Subscapularis Tears Presentation Series (Part 2): Outcomes

John Munz, MD (Houston, TX) shares the unique features and benefits of each VA proximal tibia plate, noting how the design, instrumentation, and fixation options are game-changing for treating proximal tibial fractures.

Imaging and Resection

Trauma Lower Extremities

A Deep Dive Into the Variable Angle (VA) Proximal Tibia Plates

Speaker  Proximal tibia fractures are challenging injuries, whether from high energy trauma or low impact falls. Anatomical joint reduction and restoration of alignment and stability are critical, which is why precision and fixation is key. These fractures demand versatility. To truly address these complex fracture patterns, we need implants and tools that are as adaptable as the anatomy itself. Let's start with the lateral plate. There are a number of things that make this plate unique. First, the overall contour. It's designed to match the natural curvature of the tibia in both the coronal as well as sagittal planes. When I place this plate on bone, it feels like it belongs there. The oblong holes are especially helpful. They give me the ability to fine tune the plate's position before final fixation. Approximately. The plate has cutouts that facilitate meniscal or capsular repair, and the holes for provisional wire fixation. They're placed exactly where I need them. The slope and contour of the plate, approximately, is subtle but important. It helps minimize prominence over gerdy's tubercle, which is a common issue with other plates. That lower profile makes closure easier and reduces soft tissue irritation. Post-op, we've struggled for years with plates that don't fit well proximally. This one solves that. It's anatomical, low profile, and it's user friendly. That's the kind of design that changes your workflow. Speaker  Now the high lateral plate takes things a further step. One of the biggest challenges with current implants is getting proximal enough to support the articular reduction. Often we've had to place a separate rim plate just to get that proximal for fixation. This plate eliminates that need. The proximal row of 2.7mm screws is perfectly positioned to hug the subchondral bone. That means I can incorporate rafting screws directly into my dominant plate. That's a huge advantage. It simplifies the construct, reduces surgical time, and improves fracture fixation. The direct medial plate is another thoughtful design with 6 to 14 hole options for high energy bicondylar fractures. I need subchondral support medially as well. This plate allows me to place 2.7mm screws proximally in a very subchondral location. The curvature of the plate also facilitates easy passage distally to match the tibial morphology. The direct medial plate also includes recessed areas and holes for suture placement. Whether I'm repairing the MCL or the Pez anserinus, that kind of integration saves me time and gives me more confidence in soft tissue management and the footprint of the plate. It's ideal for schatzker v fractures. It fits right at the apex of the fracture exit, which is exactly where I need support. Finally, the posterior medial plate. Speaker  This one's all about contour ability. The area at the neck of the plate was constructed to be malleable. That allows me to buttress coronal plane fracture exits more effectively. The oblong hole placement is also strategic. This hole allows for fine tuned adjustments in plate location for maximal buttressing fixation, exactly where the fracture requires. Let's talk about screws. It's one of those things that seems simple. Until you're in the O.R. and you need exactly the right length. Screw links increase by two millimeter increments all the way up to 80mm. That's rare. Most systems jump five millimeter increments after 50, which can leave you guessing or compromising. And if you need more screw length, the system goes all the way up to 95mm. So no, we don't do short screws here. As for screw types, the system includes cortical screws, cancellous screws, variable angle locking screws, and crew lock variable angle locking screws. The crew lock screws are especially helpful. They allow for interoperative compression across fracture sites as you insert them. That means I can compress and lock in one step, and because their variable angle, I can direct them exactly where I need. Avoiding joint penetration and optimizing fixation instrumentation is one of those things that can either streamline your case or slow you down. What I appreciate about this system is how intuitive it is. Speaker  Starting with the color coding, 2.7mm instrumentation is red and purple, 3.5mm is yellow and teal. It's simple, it's clean, and it makes life easier for the entire O.R. team, especially your techs who now don't have to play the guessing game with drill guides, drill bits, and screwdrivers. Everything in this system is calibrated off the drill bits that can save time and reduces error. The option for manual length assessment is also provided with easy to use depth gauges. And what about for percutaneous screw insertion? The percutaneous instrumentation is a game changer. It's efficient, it's accurate, and it keeps the procedure minimally invasive, which helps reduce soft tissue disruption. The ability to place a triple sleeved guide that fits into the plate and then drill, measure and fill without hassle is very unique among systems currently available. In patients with robust soft tissues, this can minimize surgical dissection and prevent intraoperative struggle. From plate design to screw versatility to streamlined instrumentation. This system is engineered for the realities of surgery. Every element reflects the expertise of surgeons who have encountered these challenges firsthand. These are not just tools. They're purpose built solutions designed with precision and insight to support performance in the O.R., where thoughtful design truly matters.

A Deep Dive Into the Variable Angle (VA) Proximal Tibia Plates

John A. Ruder, MD (Orlando, FL), demonstrates the Atraumatic Hip Access Convenience Kit for hip joint access. These disposable kits contain everything needed for safe and streamlined joint access, including an atraumatic access needle, SafeCut™ capsulotomy blade, and FlushFit cannula.

Hip Joint Access Using the Atraumatic Hip Access Convenience Kit

Speaker  Hello, my name is John Reuter from Rothman Orthopaedics in Orlando, Florida. Today we'll be discussing safe hip access with the use of the Atraumatic Hip Access Disposable Kit. In this kit includes an Atraumatic access needle. This utilizes a spring loaded mechanism with a blunt tip that retraction protracts while penetrating the capsule, as well as a standard access needle. These come in 14 gauge and 17 gauge sizes. This kit also includes two 1.1mm nitinol wires, as well as the Flush Fit Cannula system, which comes in both standard and extended lengths. Also included in this kit is the curved SafeCut blade or alternatively, the CapsuleCut blade. Here we are obtaining hip access via a standard anterolateral portal with the use of Atraumatic needle. We can now see here. Once we are inside the joint with Atraumatic needle, that. The blunt tip is now protected again, with the goal of this to be minimizing any risk of iatrogenic injury once the wire is placed. When we come in with the FlushCut cannula system, the obturator and the cannula engage via this chin up bar type mechanism, which does have an indicator that says press to disengage these. The camera will then engage via a similar mechanism on the bridge, and we'll click into place. Once we have our Anterolateral portal established, we will create our Mid-anterior portal under direct visualization. Speaker  Again using the Atraumatic needle. When utilizing the trampoline technique with the pressure applied to the capsule can feel the blunt tip as it retracts and protracts again. And then once we pop through the capsule, we can see here that the inner stylet is protracted to minimize the risk of iatrogenic injury. Once we are happy with our needle placement here again we use the 1.1mm nitinol wire. Create a one centimetre longitudinal incision. Come back in with the FlushCut cannula system, the obturator and cannula. At this point we'll turn the water on. Once our mid-anterior portal is established, we'll switch the camera to the Mid-anterio portal. Now, looking back at our anterolateral portal, we'll proceed with our Interportal Capsulotomy with the use of the SafeCut blade. An additional benefit of the SafeCut blade is the blunt tip, which allows you to create a larger proximal leaflet, as there's less risk of damage to the femoral head. And with a larger proximal leaflet, we'll make subsequent capsular closure easier. Now coming in through our mini anterior portal with the SafeCut blade. To complete our Capsulotomy. Now that we have completed the Capsulotomy, the use of the arthroscopic shaver, we will debride pericapsular fat pericapsular soft tissue to make our capsular closure at the end of the case easier. Speaker  Once we have completed our capsulotomy and prepared our capsule, we'll proceed with placing a traction stitch in our proximal leaflet with the utilization of a proximal Anterolateral portal, which is approximately three centimetres proximal to our Anterolateral portal and 1 to 2cm anterior. We'll utilize the SutureCast for the placement of the stitch pulling the proximal leaflet of the capsule retracting it back. Proximally will aid in visualization for anchor placement and for labral repair. So with the traction stitch here, we can actually see the separation between the labrum and the capsule here. Here, placing a second capsular stitch in our proximal leaflet through a poke hole incision just anterior to our previously placed proximal anterolateral portal coming in through the capsule, approximately aids in capsular preservation. Now, with both traction stitches placed, we see here nicely a clear separation between capsular tissue and the labrum. Here we demonstrate a three anchor repair of the labrum with the use of the Knotless FiberTak. After we obtained hip access with the use of the Atraumatic hip Access kit, and then the use of proximal traction stitches through the proximal leaflet to obtain better visualization for anchor placement. With the use of these techniques, we minimize our risk of iatrogenic injury to the chondral surface or to the labrum.

Hip Joint Access Using the Atraumatic Hip Access Convenience Kit

This animation outlines the steps for safely entering the joint using the Atraumatic Hip Access Disposable Kit.

Hip Joint Access Using the Atraumatic Hip Access Disposable Kit

The soft plastic material of the flush fit, a traumatic cannula system, and the blunt tip of the SafeCut. Capsulotomy blades are designed to reduce the risk of iatrogenic damage during access into the hip joint during hip arthroscopy procedures. Once the hip is distracted, insert a spinal needle and nitinol wire through an anterolateral portal to begin access into the joint. Use an obturator to dilate the capsule before inserting the plastic cannula. Insert the plastic obturator through the cannula by engaging the button, and place it over top of the nitinol wire with a slow, twisting motion. Depress the button behind the laser line and remove the obturator from the joint. Insert the NanoScope and bridge through the cannula to begin viewing the joint. Establish the mid anterior portal using the same steps used for the anterolateral portal to begin preparation for making a capsulotomy. Place the SafeCut blade through the cannula to begin the capsulotomy. The blunt end protects the cartilage from being inadvertently struck. Once the capsulotomy is achieved, replace the cannula through the incision to switch portals. Push behind the laser line to disengage the bridge from the scope and switch it to the mid anterior portal. Insert the blade through the anterolateral portal to complete the rest of the capsulotomy. The blunt tipped SafeCut blades come in straight and curved options with and without a handle, offering unparalleled versatility for safe joint entry.

Hip Joint Access Using the Atraumatic Hip Access Disposable Kit

Michael Swartzon, MD (Miami, FL), compares the compositions of platelet-rich plasma and bone marrow concentrate; reviews their efficacy, durability, and safety; and provides rationale for using both types of biologic treatments when treating knee osteoarthritis.

Orthobiologics

Bone Marrow Concentrate vs Platelet-Rich Plasma

OrthoPedia: Bone Marrow Concentrate vs Platelet-Rich Plasma

Patrick J. Denard, MD (Medford, OR), describes a surgical pearl to maneuver and open the CuffMend™ graft spreader in a tight subacromial space to position the ArthroFlex® human dermal allograft.
ArthroFlex® is a registered trademark of LifeNet Health.

SpeedPearl: Opening the CuffMend™ Graft Spreader in a Tight Space

Sometimes you can encounter a tight space when doing a koufman augmentation. So one tip I like to do is start by having your wrist turned away from you. And then as you insert the lateral cannula, you want to pronate toward you as you open the graph spreader. That will really allow the graph spreader to lay right over the top of the rotator cuff.

SpeedPearl: Opening the CuffMend™ Graft Spreader in a Tight Space

Edward Haupt, MD (Jacksonville, FL), presents a case using the NanoNeedle™ scope 2.0 and release kit in an endoscopic gastrocnemius recession procedure.

NanoNeedle™ Scope 2.0 for Gastrocnemius Recession

Speaker  Hello, I'm Eddie Howe from Jacksonville, Florida, and today we're going to talk about NanoNeedle scope for Gastroc recession. The current system that you're used to uses a scope tower as well as normal arthroscopy trays. Obviously this is cumbersome for the team, and there are improvements that can be made upon this to make it easier for you and for your surgery team. The NanoNeedle scope is a 1.9mm scope with a single use kit has everything you need, both for the arthroscopy or endoscopy portion and also the instruments you need to complete. The Gastroc recession is in the kit, and the kit used for the Gastroc recession specifically comes with every instrument you're going to need for the case. So there's a translucent cannula with an obturator to find the right place. There's a plane finder, which works as a switching stick. If you can't get in the right spot, multiple different blades and arrested for visualization as well as several Q-tips in case you need those. So why NanoNeedle endoscopic gastroc recession? For me, I get this much range of motion that you're seeing on the screen with very little incision and no extra trays of process, which is huge for my team. So obviously I'm showing you an image. They're gaining about 15 degrees of dorsiflexion with just a couple poke holes. So how do I set up the room? This is my exact setup pictured here where I'm looking off to the left to a NanoNeedle console. Speaker  It's a typical supine setup for me. You can use a mini or a large C-arm, a thigh or calf tourniquet. If you use a calf tourniquet, just be smart that you place it high enough that you're not going to be in the way of your instruments here. I'm doing this with an ankle replacement, so you can do it with as complicated of a case as you want. You're going to want to have a towel bump ready for a more working room as you're working with the leg, and you're going to hold the foot with your chest for a portion of the procedure. So how do you start this? You're going to make a 3 or 4 millimeter incision just a little bit bigger than a knife blade at that junction of the gastrocnemius and its aponeurosis, you on the side of being a slightly distal incision, as I have pictured here. Notice that the leg is on the towel bump. To give me some more room, I'm going to make the incision and then blunt dissect down to the crural fascia of the leg. I usually use a hemostat for this, and once I get to the fascia, you're going to perforate that. I typically use the pointed obturator to do that, but you could also do it with the snap. I think it's easier to do it in one step with the pointed obturator. Speaker  Do this with the ankle in plantar flexion so that the calf muscle is loose. It'll be easier to find your plane with the ankle plantar flexed. You're gonna place your cannula into position where you're in between the crural fascia of the leg and the gastrocnemius aponeurosis. You can check with the scope before you perforate laterally. You're going to eventually need to make a lateral incision, but you can look before you make that incision and make sure you're in the perfect spot. So here's an example of a first pass. You'll notice that when the video plays that you can't see at the other side. Because I haven't made that incision yet. When I'm looking in and I'm going to be in between the fascia of the leg posteriorly or on the bottom of the screen and the gastroc aponeurosis on the very top of the screen, which is that white band. It's a little too much fat on that image, obscuring my view of the aponeurosis. So I'm going to use the rast included in the kit to mobilize that soft tissue off of there. We're going to pass a few Q-tips and check again. So here's me placing those Q-tips through the cannula that's already in there, showing how easy this is. And you can obviously see the NanoNeedle scope on the bed as well as the blunt obturator. The view you want is going to be with the cannula. Speaker  Obviously in place, shows the gastroc aponeurosis at the top of the screen and the crural fascia right behind it, and it's a perfectly white gastroc aponeurosis. So that's an image there on the left. And also what it looks like with the hook. So you can see even better than you can open with the scope. Don't proceed until you have a great view. So once you have that perfect view, puts the operator back in, perforate the crural fascia laterally, tent the skin over the obturator and make a stab incision with a knife and pass that out the other side. You'll need to instrument through the cannula with the scope and the hook blade. A great question is how do you cut with a hook blade? So you're going to tension the fascia with the ankle dorsiflexed that tension is going to help the blade cut and use the sharpness and the curvature of the blade. Hook it onto the aponeurosis, gently pull it and cutting as you go, but make small twists with your wrist to keep it from getting snagged. And here's a few videos of exactly that. So the hook blade is going to be placed right against the aponeurosis. And then you can see it. Sometimes it cuts very quickly and easily. But other times, if it seems like you stop making progression with the blade, just make little twists like I'm showing right there to continue to advance under control, you want to avoid the blade plunging out of the leg, and you do that by making just gentle little twists. Speaker  When you get snagged, you can see it's easy to even go back and release a little band there that maybe not captured on the first pass without having to pull all the way out. Here's another video of the same thing. Gentle traction with the hook. Gentle twist leads to a very precise cut going all along the length of the gastroc aponeurosis. It's very subtle. It's very similar to the way you use a Cobb elevator, where you use gentle twisting of your wrist to elevate the tissue. So here's kind of that, the full view. I have the camera in one side of the cannula, or passing the hook all the way in and hooking it against the gastroc aponeurosis with a nicely tensioned with ankle dorsiflexion. And you're going to notice I'm going to start to pull a little traction doing gentle twists through the hook as we go. Very subtle twists and I'm releasing the Gastroc aponeurosis as we go. You can notice the soleus fascia is behind the Gastroc aponeurosis there. So this is a perfect release as we're moving along here that the soleus fascia is left intact. And that was it. So it's a very quick, straightforward case. Once you find your plane obviously with very small incisions. Speaker  And this is exactly why I do it. There's preoperative image on the left there. Maybe we can dorsiflex that to neutral right after the post-procedural, I can get another 10 or 15 degrees exactly what you'd get with an open gastroc recession. The tiny incisions than I would argue it's a faster procedure. So thank you for watching this. I think the indications for this procedure are contraindications are the same as any gastroc recession. The pearls here is the gentle twisting of the hook allows for easy blade passage. This procedure, once you get used to it, really shines and individuals. You'd have to make a large incision for your Gastroc recession. So obese people, overweight patients, individuals with a larger leg. I think the pitfalls to be aware of is the exposure, like any surgery, is key. Don't pass the hook blade unless you can see well and make sure you can see well before proceeding. My recommendations for somebody starting out with this is perfect. The location of that portal incision. That'll be easier with skinnier patients in the beginning. You can expand your technique as you get better. And you also want to perfect the location of your cannula underneath the fascia as well. I think the key there is paying attention to the position of the ankle. Keep the muscles loose. When you perforate the fascia, tighten them up as you're passing the blade and putting your cannula in position.

NanoNeedle™ Scope 2.0 for Gastrocnemius Recession

Paul Saluan, MD (Cleveland, OH), demonstrates an all-epiphyseal ACL reconstruction (ACLR) using the all-inside QuadLink™ technique with pediatric small-angle marking hooks and the FlipCutter® III drill to safely avoid the physis. Dr. Saluan also uses the new FiberTag® TightRope® II implant, featuring the TightRope II button, a flat-tape TightRope loop, a shorter minimum loop length, and an improved atraumatic needle.

All-Inside, All-Epiphyseal QuadLink™ ACLR: FiberTag® TightRope® II Implant and Pediatric Guides

All-Inside, All-Epiphyseal QuadLink™ ACLR: FiberTag® TightRope® II Implant and Pediatric Guides

Marc Szadkowski, MD (Lyon, France), presents a case of a 51-year-old male with a paracentral disc herniation at L3-L4, treated using an endoscopic trans-SAP decompression approach.

Spine

Endoscopic Trans-SAP Approach for a Paracentral Disc Herniation at L3-L4

Speaker  Hi, I'm Mark Szatkowski. I'm an orthopedic surgeon from the Santee Group from Lyon in France. And today I will show you a trans Sapi approach on l3-l4 level for a paracentral disc herniation. So the trans Sapi approach gives the surgeon the opportunity to increase the power of foraminal techniques to reach difficult anatomical sites by removing extra articular bone from the sap. This approach has many advantages. First, you duck on a highly secure zone far from the exiting nerve. You increase the size of the foramen to explore the canal, and you have a better view on the shoulder of the transversing nerve root. This is the case of a 51 year old gentleman, a heavy worker, and for one month he had a bilateral posterior leg pain. And he came in the emergency to the office because for two days he had weakness in the right leg. On the clinical examination, I had a positive straight leg test, 30 degrees bilateral. And the patient had a motor deficit on the dorsal flexion and on the quadriceps. Here is the MRI. And on the axial view you can see that the dura is severely compressed by your paracentral disc herniation on the level l3 l4. Here you can see in red the disc herniation that is located slightly more on the right side. In green you can see the dural sac that is severely compressed on the sagittal view. Speaker  You can see the level l3 L4 with a disc herniation that goes cranially and caudally. And here you have the same view with the disc in red at the L3 L4 level. The interlaminar window that you see in red is lower than the disc level. So if you want to decompress the dural sac in an open fashion, you have to remove a lot of bony structures, including the ligaments. So the main advantage of the trans sap approach is to leave all the posterior structures intact, and to remove a small extra articular piece of bone to go inside the canal to have a better view on the disc herniation and the dural sac. The planning is to remove a piece of bone that you can see in blue with the dedicated reamers. After docking on the sap here, you see the AP view. First you have to draw a vertical line, which is the midline and a horizontal line, which is the level of the injury. Then you draw the direction you will have to use for this technique, and you will start always with the lateral X-ray. And the aim is to dock more shallow than in a transforaminal approach. On the sap here you can see a lateral view of where you have to dock. Then by using Corona Reamers, you start to create a bony channel in the sap. Speaker  Here you can see the bony channel. You progressively increase the size of the channel in order to put the working channel inside. On the left video, you can see the bony removal and the remaining ligamentum flavum hiding the dura. You can remove this thin layer if you need it with a Kerrison punch. You can also drill the tip of the sap if you want to go more Cranially. On the right video, you start to see the dura that is proceeding. Now as we started to remove the disc herniation, now the dura and the nerve are free. You can see the transversing nerve root and the PLL you can easily reach with this approach to cranial part of the disc. As you can see on the X-ray done with the probe inside for the postoperative period, we ask the patient for four weeks to work and to avoid active physiotherapy at one month post-op. After examination by the surgeon, the patient can return to daily life activities while starting active core training. So this is a great option for patients because you can address multiple conditions like migrated disc herniations, foraminal stenosis, and even recess stenosis combined with disc herniation and without removing any ligament or facet, which ultimately gives the quickest recovery. Thank you.

Endoscopic Trans-SAP Approach for a Paracentral Disc Herniation at L3-L4

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

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

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

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

Expanding on the trusted Syndesmosis TightRope® platform, the Syndesmosis TightRope PRO implant is the next generation in syndesmotic fixation. Updated instrumentation and lower-profile implants provide efficiency by design, enabling effective treatment of syndesmotic injuries.

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