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

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FiberTape® Sternal Closure for Rib Approximation After Thoracotomy Incisions

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

FiberTape® Sternal Closure for Rib Approximation After Thoracotomy Incisions

E. Lyle Cain Jr, MD (Birmingham, AL), demonstrates surgical steps, during a live surgical case, using tensionable Knotless FiberTak® soft anchors to repair a posterior glenohumeral labral tear. Dr. Cain describes the technique using the Rotation Lasso suture passer to create simple and mattress repair stitches. The final repair shows an anatomic, low-profile knotless repair.

Re-Live Surgical Technique: Posterior Labral Tear Repair With Tensionable Knotless 1.8 FiberTak® Soft Anchors

This case represents a posterior labral repair in the left shoulder. The patient had tried conservative treatment with rehab, was diagnosed with a posterolateral tear by MRI. This procedure was a posterior labor repair arthroscopically using 1.8 Nautilus FiberTak anchors. The arthroscope is in the anterior portal, viewing posteriorly. You can see a spinal needle that's been placed for an accessory posterior portal that will be used for anchor placement, as well as suture passage. The FiberTak drill guide has been placed through the accessory portal. As you can see, there's a black line which indicates the maximum concavity of the drill guide. And this drill guide can be turned in order to allow aiming towards the center of the glenoid, which is critical for the best bone purchase for these anchors. We then elevate the hand and push down against the deltoid to get a nice vertical passage of the drill into the inferior glenoid bone. This prevents skiving off the inferior bone. I like to cycle this drill in and out a couple of times to clear the bone debris. We then use hand pressure to apply the anchor into place. And it's impacted with the back of our hand until it's fully seated. The centering sleeve keeps you from being off center and allows excellent placement of the anchor. Once the anchor is applied, we use a rotation lasso to pass the anchor suture and the repair suture through the labrum. As you can see, the rotation lasso allows you to move the lasso and rotate it perpendicular to glenoid face. We'll try to go a little bit inferior to do a little bit of a superior capsular shift. So we'll grab about a centimeter of capsule and labrum, come out on the glenoid bone junction and then pass the rotation lasso into the shoulder. We then spin the lasso to make it perpendicular to allow easier passage. And we reach through our straight posterior portal with a loop grasper to grab the sutures and do an all-inside shuttling of the repair stitch. In most cases, I like to do a mattress suture on the lowest part of the labral tear. I think this gives you better labral biomechanics, as shown by millet and others, and also brings the labrum up against the neck of the glenoid, where healing should be better. Repair stitch is pulled through the SutureLasso, then the lasso is converted to pull the repair stitch through the labrum and capsule. At this point, we want to convert the anchor. I'll grab the repair stitch and the round conversion stitch, which has a loop through the accessory portal, will then load the repair stitch to the purple mark in the loop, which gives you proper length for passage. And then we pull the opposite end of the suture passage stitch until the anchor is converted and the repair stitch goes through the soft anchor. At this point, I'll cycle the repair stitch. Several times I'll pull it down tense until we get a good approximation. I'll leave this repair stitch intact so I can tension even further after I get the second anchor. In the second anchor is in place with the drill guide again in the accessory portal. The turn of the curve posterior at this point. So I'm more vertical into the bone and have a better angle, and the drill is cycled several times in and out to get the bone debris out of the tunnel. The anchor is then placed by hand, centered using the centering sleeve, and then impacted by hand into the bone to set the anchor in place. This repair stitches then shuttled through the labrum out the capsular attachment and is ready for conversion of the anchor. The anchor is converted through the anchor placement portal, which is the posterior accessory portal, and then as this anchor is tensioned, I like to grab through the posterior cannula, the labrum, and advance it so that I get a nice good tension in the labrum. I will then grab the original mattress suture again and tension it one last time before I cut the sutures. We then sequentially apply up the posterior glenoid. Simple sutures using the knotless device. And for most cases, on the opposite side of the shoulder, this time being the anterior portion of the shoulder. I'll put a simple anchor in order to act as a ripstop anti propagation stitch, and also tension the anterior band of the inferior gluteal ligament. If this were an anterior labrum, I would typically put another anchor on the posterior inferior portion. Again, tensioning the axillary pouch, the hammock effect, and promoting a ripstop effect to keep the labrum from propagating the opposite direction.

Re-Live Surgical Technique: Posterior Labral Tear Repair With Tensionable Knotless 1.8 FiberTak® Soft Anchors

The Arthrex ultra-minimally invasive endoscopic spine portfolio is a comprehensive solution that includes enhanced visualization with the Synergy camera system and operative endoscope, ergonomic WishBone™ and ring-handled instrument options, a steerable electrosurgery probe, and an endoscopic instrumentation system.

Arthrex Ultra-Minimally Invasive Spine Portfolio Overview

Arthrex Ultra-Minimally Invasive Spine Portfolio Overview

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

Misty Suri, MD (New Orleans, LA), discusses patient-reported outcome data from his first 300 cases of CuffMend™ rotator cuff augmentation.

My First 300 CuffMend™ Rotator Cuff Augmentation Cases

Hi, my name is Misty Surrey from New Orleans, Louisiana. I'd like to share with you my experience of my first 300 CuffMend cases. Having done more than 300 of these cases, I've had about an even split between augmenting full thickness repairs and augmenting articular and bursal tear debridement for my patients. My goal is to achieve the best possible outcome with the lowest chance of retear as possible. Cuffmend augmentation gives my patients the highest chance of healing. And let me share with you some of the highlights of the data I have on these patients. So here's my first subset of patients with rotator cuff repair augmented with CuffMend versus the control group. As you can see with my patients who have gotten to the two year follow up time point, there's a significant difference observed the six week mark compared to the control group, and this is maintained until the final follow up. Similar improvements were noted at the three month time point for the aces score, and also for the same score. Similar improvements were observed significantly from the three months to the final follow up. Now, looking at the second subset, which is the rotator cuff debridement with CuffMend compared with debridement only. Now these were 35 patients that got to the two year final follow up time point. Similar trends with pain scores were observed, highlighting significant differences achieved at an earlier time point of the six weeks versus the control group. These results were sustained at the final follow up. Aces scores also improved early on and were also sustained. Seen scores improved in a similar fashion with sustained results. So my PT colleagues noticed patients had less pain and were progressing faster. This is an example of a patient after a medium cuff repair that was actually doing high level military extractions, four weeks after cuff repair with CuffMend.

My First 300 CuffMend™ Rotator Cuff Augmentation Cases

The endoscopic-length whisker blades, compatible with the SynergyResection™ system, provide an innovative solution for effective removal of soft tissue during endoscopic spine procedures.

The endoscopic-length whisker blades, compatible with the Synergy&lt;sup&gt;Resection&lt;/sup&gt;™ system, provide an innovative solution for effective removal of soft tissue during endoscopic spine procedures.

Endoscopic-Length Whisker Blades: Features and Benefits

Endoscopic-Length Whisker Blades: Features and Benefits

At the Orthopedic Technology and Innovation Forum, Patrick A. Smith, MD (Naples, FL), reviews the key lateral knee anatomy involved in anterior cruciate ligament (ACL) injuries and outlines a modified lateral extra-articular procedure that can improve pivot-shift stability.

Next-Level Lateral Extra-Articular Tenodesis (LET)

OrthoPedia: Next-Level Lateral Extra-Articular Tenodesis (LET)

The Arthrex Elbow Fracture Plating System provides a comprehensive portfolio of distal humerus and olecranon plates. Designed to treat all fractures, the set comes with KreuLock™ locking compression screws, allowing the surgeon to both reduce the plate to bone and compress across a fracture. The plating portfolio is perfectly complemented by Arthrex soft- tissue procedures and fracture reduction, including LUCL/MUCL InternalBrace™ ligament augmentation, FiberTape® cerclage, and the ElbowLOC® elbow positioner.
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.

The Arthrex Elbow Fracture Plating System

The Arthrex Elbow Fracture Plating System

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

John G. Kennedy, MD (New York, NY), discusses diagnostic and treatment applications using the NanoNeedle™ scope 2.0 for ankle arthroscopy conditions such as anteromedial and anterolateral ankle impingement.

Revolutionizing Ankle Arthroscopy Using the NanoNeedle™ Scope 2.0

Hi, my name is Doctor John Kennedy. I'm an orthopedic professor at NYU Langone in New York. We're going to be talking today and showing the new 2.0 nano needle, and we're going to be looking at it specifically in the ankle joint at the anteromedial impingement and anterolateral impingement. And today we're going to be going how do we diagnose this. And also how do we fix it. And so with no further ado we'll carry on. So we're going to be talking this morning about anterior arthroscopy using a nano needle. And the new 2.0 nano needle. And the first thing we're going to be talking about is how do we set this up. So this is a procedure that you can do in the office. Or indeed you can do it in the operating room. And the way that we do it is exactly the same. We start off always with identifying the superficial peroneal nerve. And you can see that running on the lateral side here, that is the structure that is most at risk. So we always identify that with the third toe for toe flexion sign. And that then makes that more prominent. Our portal will be slightly lateral standard entry lateral portal to that. And then we'll have a medial portal as well. And both of these will be a working portal and a visualization portal. So in the office, once the patient is settled in then we identify these. And the first thing that we do is we give them a local anesthetic with marcaine a lidocaine 1 to 1 ratio. And we inject that into the joint. And we can see here and typically we'll give about 4 or 5 cc's into the medial aspect. And then we come over onto the lateral aspect again always recognizing where that SPN is. And then we inject into the lateral aspect of the joint as well. After that then we leave the patient for about 5 or 10 minutes while we get everything set up. And I think it's important at this point to underscore that in-office needle arthroscopy is truly a team sport. This is not just all about the surgeon and patient. We have our nurse or nurse assistant with us who's versed and skilled in this, and also our local rep. I think that is critical for this because when a patient is awake, they will recognize and certainly see if people are not familiar with what's going on. So I think it's critical that everybody is on the same team. Everybody plays a different position, but collectively we play to win. So that's the setup for anterior arthroscopy using the new needle scope. So for the next portion of this, what we're going to do now is make standard portals on the Andromeda and Anterolateral aspect of the joint. And again we use an 11 blade. And we just simply go through the skin. We don't have to go through the entire length of the blade, just about a 2 to 3 millimeter incision. And because in the end, of course, we're not going to be using sutures and it's just steri-strips. So we go through this into the capsule, gently remove that, and then we have our trocar, which is slightly beveled. Again you want to protect the underlying structures. Put your finger just at the about a centimeter or two from the tip and then advance in. And we're into the joint and you can feel that pop and you have to represent you We have to let the patient know that they will feel a pop. They should feel no pain whatsoever. There's the capsules are completely anesthetized, as is the as is the joint. So they'll feel that mechanical pop and hear it, but they won't feel anything in terms of pain. Then we remove this and then we put in our new 2.0 needle. And you'll see, once we get into the joint, you can see automatically how really clear this is on the top portion of the horizon. There you're seeing the tibia and this is the talus. And if we advance now towards the lateral side you can really see the depth and clarity. And of course that all comes from the the new 720 by 720 sensor that we have, which is an order of magnitude better than what we've been using before. And you can really see how clear this is as we're looking over in the lateral side. Because this as we move over to the lateral side then you can trans illuminate. You can see some of the AI TfL you can see some chondral damage there. The next portion of this we're going to use the needle. And the needle will then identify our lateral portal. So again we've predetermined where that's going to be. And you can see and we just take a picture of that. And of course all the time you're talking to the patient because the patient at this point wants to know. And just for the purposes of this demonstration, we're going to say this patient had a recurrent ankle sprains and this ligament here. The atfl or Bassett's ligament is hypertrophic, and that can often cause snapping and damage the cartilage, as indeed it has done here. So once we've put the needle in, then we would throw the needle. We use our 11 blade once again. And we just make that small incision through there. This is a 3.5 shaver. We use a three and a 3.5. This is a receptor. And you can see we've come through that lateral portal. And this will have the ability to shave everything from the lateral side, right across the joint, right over to the medial side. And at one point when we need to look at the medial side, we'll just simply change portals. One thing to note here on the when you're looking outside the joint is how we hold the actual needle scope. It's important that you stabilize that against the body, and that reduces any emotion or aberrant motion that you might get from if you were choked up here. Any sort of you can certainly get some tremor in your hand if you're up here. But if you're stabilizing against the joint, that tremor is eliminated or reduced. So here we are. We're in the joint, as I said, for the sake of demonstration, we're saying that this is a hypertrophic atfl or an anterior ligament of the of the ankle joint. And this is commonly syncretized or scarred after a recurrent ankle. Sprains. The atfl is underneath here we can dive down here and we can see the atfl will be underneath there, but the atfl is the one that becomes hypertrophic. So we can use the shaver and we can start shaving away on that. And we take you can actually take the entire this ligament away without compromising ankle instability or ankle stability. And, but we're just taking the anterior two thirds of this fascicle away. And you can see the damage that it's done to the control surface here. And I'm just going to introduce, actually to show you that I'm going to use you. This nice new probe that we have is graphite covered. So it reduces glare. And it again the profile of this fits through our portal is very nicely. So again there's going that is going to be the remnant of our TfL or Bassett's ligament underneath here we can dive down and we can see down there is the Atfl and we don't want to touch that on this particular model. And so we're just resecting that. And you can see as the talus snaps over that hypertrophic edge, it can cause damage to the Taylor control surface, and you can see the wear that's occurred here over time. And of course, that will create a lateral osteochondral lesion at some point if that's not addressed. So that's really the lateral aspect. You want to make sure when you're dealing with anterolateral impingement that you always dorsiflex. And you can see now that there's really no impingement there. And there's a nice gliding motion. But if there was impingement and I'll take the shaver again, you can use the shaver, but oftentimes we'll use a bur. So we'll just as we're waiting for the bur to be loaded, we'll just show you in terms of the shaver, we can just shave away some of that bone and we'll just pour it instead of oscillate. We'll just put it on forward to shave away. Again, remember that this is an in-office procedure. You just have to warn the patient. Although they will have no pain at this point, that they will feel the vibratory sense within their joint and not to be alarmed with that. But again, you can see we're getting nice reception if this is a large exostosis or osteophyte, and we'll change that to a three or a four bur, which we'll do now again for the purpose of demonstration. And again, you can see how really critical it is to have your assistant just well versed in knowing what the next steps are going to be. And I think that is, as I was saying earlier, is so important in terms of a team sport. This really is a true team sport, particularly when the patient is awake and is aware of everything that's going on. It has to look like a seamless transition from player to player. And that's particularly so because at some point we need to wash out the joint or lavage the joint. And our company representative will be there and knowing when that occurs so that they're ready on standby. They don't have to struggle to find the the pump. So they're ready to do that or ready to take a picture. Because there are times when you're holding the camera that it is difficult for the operator to address or to take a picture. They'll lose that picture. So the nursing assistant or the rep will take the picture for you. So that's really a demonstration of the anterolateral impingement. So we've taken soft tissue away and we've taken bone away. And of course if that's all we do we can leave half of it undone. It's more common on the medial side, but oftentimes on the lateral side down here, just as you're getting into the neck of the talus, they may have an exostosis here and you don't want to miss that. So always make sure you dorsiflex that joint all the way to make sure that there is nothing there that's going to cause any impingement. So on this model we can see that that's a really nice gliding moment motion. The atfl or that hypertrophic Bassett's ligament is gone largely. We can take a little bit more away if we need to. So again, we can now move our camera over to the medial side to look at anteromedial impingement. So we're introducing now our new 2.0 beta. This is more robust than the previous one. And you can see it's got a really nice cutting profile to it. And again we're simply resecting that anterolateral impingement. So we're able to cut that away. And sometimes you just need to do that to create a surface that the shaver can grip on a little easier. But you can see how nice is a really good tactile feedback on this. You can hear and feel those clicks. And again, it's always useful when a patient is looking at this. It looks like this is an industrial instrument. So it's much better to show the patient that this is really quite tiny. This is the profile. And this is just two two millimeters. So it's very, very small of course. Enormously magnified for the patient to see. So you can see we've taken that away. And then we'll just put our shaver in again after that to clean that up and make that as smooth edge.

Revolutionizing Ankle Arthroscopy Using the NanoNeedle™ Scope 2.0

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

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

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

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

This animation demonstrates capsular closure at the end of a hip arthroscopy procedure using a SutureCast™ suture passer to pass 1.3 mm SutureTape sutures.

Capsular Closure Technique Using a SutureCast™ Suture Passer

Capsular Closure Technique Using a SutureCast™ Suture Passer

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

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

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