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INFORMATIONSMATERIALIEN FÜR KUNDEN

The Synergy Power™ system is redefining versatility, reliability, and performance in ambulatory surgery centers (ASCs). From streamlined workflows to unmatched power, learn how this system can transform your ASC.

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Empowering ASCs and Beyond: The Synergy Power™ System

Empowering ASCs and Beyond: The Synergy Power™ System

Randy Lovell III, MD (Grand Rapids, MI), demonstrates the entire process of performing an endoscopic carpal tunnel release in the office under local anesthesia. He shows his local injection technique, reviews the NanoScopic™ release system’s benefits, and demonstrates his closure technique.
Video timepoints:
0:00-5:40: Administration of local anesthesia
5:40-8:50 : NanoScopic Release System review
8:50-15:15: ECTR procedure under local
15:15-16:25: Closure

Live Surgery: In-Office Endoscopic Carpal Tunnel Release Using the NanoScopic™ Release System

Okay. This is doctor Randy Lovell, and we are going to take you through the numbing process for a wide awake local anesthetic. No tourniquet. Endoscopic carpal tunnel release. This first portion is going to be simply the preparation phase and the local anesthesia phase. So we're looking at a left wrist. I begin by palpating palmaris longus. Most of the time it's pretty easy to feel. In this case, she's got a nice FCR and a palmaris longus right there. I try to just straddle palmaris. That tends to be a really good radial starting point and then head towards the FCU, but I don't necessarily reach the FCU in terms of proximal distal, anywhere from five millimeters to a centimeter proximal to the wrist flexion crease is going to is going to work. And then I also map out Kaplan's cardinal line and the radial aspect of the ring ray. And even though we're not doing anything up in this area, these are nice reorientation Landmarks, if you will. When you're in your loops and the case is proceeding, it's nice to have something that you can quickly reference in case there's movement or something shifts. You can always quickly reflect whether through your loops or around your loops, to know that you're, you're in a safe spot and doing the right thing. So the marking is done. Just a little bit of alcohol on the skin, and we use ten millilitres of 1% lidocaine with epinephrine 1 to 100,002 total pokes. First poke I've already prepared the patient. It's kind of like a three out of ten in terms of pain. Bunching the skin up pulls the skin away from the nerve and gives you a nice target to shoot at. Poke three. Two one. Good job. And I don't move the needle. It's a 27 gauge needle. It's just in the sub-q space. So it's below the skin, superficial to the antebrachial fascia. And I like where the medication's going in this particular case. If it's ever moving into an area that I'm not happy about. I rather than use the needle to do it, I simply will use my free hand and massage the the fluid back where I want it. Kind of like a tube of toothpaste. It's a much more comfortable way to manipulate the fluid without using your needle to redirect it. Okay, little break here. And so needle comes out. That's the worst part. She did great. And you can see this is about what you want to see. Kind of a raised area that that encompasses your entire incision. And if you're going to hedge it one way or another, a little bit on the proximal side is a good way to go. And then I just sort of massage it in. That tissue is rapidly getting anesthetic so that when we add additional medication or that second poke if you will, should be painless. The patients also been prepared that she may feel some pressure building up in her palm. And if it's ever too much to let me know and I simply stop adding medication until it becomes numb again. But it's a very effective block. It is a block that you could very easily do an open carpal tunnel with very easily. It's by far the most tolerated and comfortable block that I've experimented with doing local anesthesia, endoscopic carpal tunnels. The local is not in the carpal tunnel. It will sit as you're about to see. It sits superficial to the transverse carpal ligament, but deep to the skin of the palm. And this is about what you want to see. Some are already starting to see some blanching from the epinephrine. Here comes the second poke. And this begins again in the form where she's where she's numb. She will not feel this poke. And then once we're in, in the right plane, I keep the needle very low. And we are just slowly adding medication. Doing okay? Okay. So what I want to see is This little rise right in line again. This is another good reason to have that extra marking is I just want to see ultimately sort of a rectangle. Overlying the carpal tunnel proper. You doing all right? Yeah. It just feels weird. Weird, but not not super unpleasant. Okay. And again, we're just pushing in very slowly. I don't advance my needle until I know that there's some medication out in front of it. And it's just going in nice and smooth. The fewer times you move your needle, the better. The patient has no sharp experience with that needle. It's just sort of a pressure phenomenon at this point. Almost done. We got about one milliliter left. But ten I have found to be more than adequate. Quit. And that's it. Excellent job. The hard part is done. But you can see this is you could absolutely do an open carpal tunnel right here if you needed to. And then the next critical step is time. You need to give this bloc at least 30 minutes. But during that stretch the patient is free to sit up, move around the room. If they have family with them, they can they can just sit with them and chat. These two kits have already been dispensed sterilely, so we'll do the unboxing of both of them. I'll give you that first first kit has the actual center line device, which is this handpiece here. It's very lightweight, but it's lightweight and also very sturdy. It handles very well. It remains light because the camera that we put into it is also extremely light. So it's maneuverable, Durable, very light, but also it's very stiff. There's no sense of flex or flimsiness to it. So in that regard it's been very nice and easy to learn and control. I also really enjoy the fact that the the housing is clear. And so the view when you're performing the procedure, you can not only see at the end where the work is being done, but you can also see to the sides, which adds a huge layer of safety as well as eases the learning curve a bit. So that's the centerline device there, a very nice two function instrument here on one end, a little bit of a spoon apparatus, which is used to remove the synovium from the undersurface of the transverse carpal ligament. It does a great job of that. And you'll see that in action. And then on the flip side is a classic dilator which which helps give the a little more room for the device. Box number two. Also sterile. Sterile packed has the Nanoscope and it is just a single device. Leave the cap on. That is for calibrating before the case begins, and you'll see that in just a second. And it's just a single cord. It plugs into the monitor which the current iteration is basically the size of a laptop. And we'll pass that off. So we just simply take that plug it in saying connecting. So now that we're plugged into the monitor looking back at the camera, we keep the cap on for calibration. Hit either button one time and it takes about five seconds. And the calibration will complete here in a second. All right so that's done. We've got plenty of cords. So you got a lot of flexibility in how you set your room up. Now at this point we can pull the cap off. There's your camera. This just simply inserts into the center line. Underline. And there's a little bit of a twist and a snap at the end. If you orient the flat side of the nanoscope vertically or I guess away from the palm, and that orients your view on the monitor properly. And that's it. That's it for setup. The trigger. We didn't talk about that. The trigger on this device is just a little spring device here. And. And when you push that down, the blade at the very tip is deployed. When it's released, it's safely protected inside the housing. So we'll just set that aside and we'll get going. So now we're back looking at the left wrist here, these are markings from before. Patient has been anesthetized for right around 30 minutes. You can really see this white shadow or halo which is consistent with the epinephrine causing blanching. And so you can see that the carpal tunnel itself is widely anesthetic simply from the markings there. And then obviously we're numb here too. We'll check that up on your forum. I'm going to give you a little pinch. Do you feel a little poke there? Okay. Do you feel anything sharp or pokey here, here or here? No. Okay. Movement touching pressure is going to be normal. No pain. All right. We'll get started. Occasionally we will. There's venous structures traversing this incision. And it's almost impossible to completely avoid them. But the epinephrine helps. And skin retraction really helps. So at this point it's just simply mobilizing the skin. And we're working our way gently down to the antebrachial fascia. More often than not, you can see your palmaris longus. Longest. And if we get that in good view, that's a really good spot. To place your retractor there. In there. So that's great. And. What we're trying to see is the tight white fibers of the antebrachial fascia. We simply grab small amounts of it away from what would be the nerve and make small little openings, and eventually you'll see a little rent. And I'm not sure if that shows on the video, but there is an opening. Now, if we get in there and do one good spread there, I'm looking right at the median nerve. It's right there. Thus far we've not made any contact with it at this point. I like to hang on and do a little spreading below the fascia, a little above. And at this point we can see safely in the midline and we release released approximately under direct view. Shift our attention to the distal edge here. It's really important that you don't release this too far at this point, because you can sometimes lose your handle, if you will, and stay there for a second. Come on out so that those prongs are are facing away from the nerve, and it's controlling that leading edge. And then at this point, I as the surgeon, I like to hang on to this. Your assistance will frequently try to take this out of your hands. But I like to hang on to this because it keeps me connected to the patient. Wherever my hand goes, she's going to go. I also place my finger directly over the path of the carpal tunnel release. This gives me a second, a second point of safety, a second point of control where I know exactly what's happening, that I'm in the right spot, I can, I can, I can see what I can see, but that gives me a tactile feedback that we're in the right spot at this point. We go to the elevator with the tip oriented upward, and I try to engage. As soon as I'm past the the skin hook, I try to engage the ligament and just small little pushes and work my way in. And until I feel sort of a nice, grating washboard sensation, I'll also drag the device in an older direction and I can feel the hook, the hamate. And that way I confirm again that I'm in the right spot. Flip it over and we go to the dilator pressure here. Okay. And we're just about done. So at this point this comes in low. I prefer an overhand grip. I typically use my thumb. I think some guys like to use their fingers. This comes in real low. Again. It engages that leading edge. As soon as I'm there, I'm lifting up against the ligament, which helps keep things from getting in the way. And at this point, my eyes are fully oriented to the monitor. So we're entering in to that space, and we're seeing very clearly the transverse fibers of the ligaments, very tight little pressure. You're doing great. So when I see that and there's no response from the ligament, I know I'm just past it and I'll release I'll release about half of it. But she's still pretty tight in there. Now we can start to see some separation. And what you can't see that I can feel. I'll leave that muscle alone. So the healthy muscle I'm going to leave alone. We're already fully within the release ligament, and then I'll just re-engage the ligament the rest of the way, and we'll do a final double check, and we'll come back in. And what you can see, because the housing is clear, you can see radially, and only that the ligament is completely released on both sides. If there's still some white fascial bands, I'll, I'll generally try to release those if there's. But obviously we're extremely decompressed at this point. Leave the muscle alone. One other comment is we've been in this space now for a bit. Normally you wouldn't, but there is absolutely no fogging. So there's no interference of your view because because of the nature of the device, you do not have to apply anti-fog or anything, and there's just no misting or anything interfering with the view. It's it's clear as can be. And we're done. How'd you do? You're good. Yeah. All done. You did great. So closure can be whatever you like. My preference is, in most cases, a subcuticular in a somewhat traditional fashion. I do leave the two ends out and I tie them together. And it's it's been very effective, a very effective closure. And I like just a clear, occlusive dressing. This allows the patients to shower right away. As long as the plastic is adherent, they can shower immediately, which is a nice convenience for patients. And we'll do an ace wrap. Patients are allowed to remove this at their desire. But I do like a little just a little compression. Keep some swelling down, keep some bleeding down. And and then the patients don't have to look at their incision. But lots of people decide to take this off after a couple days or day one. That's fine too. It's really what the patient wants to do.

Live Surgery: In-Office Endoscopic Carpal Tunnel Release Using the NanoScopic™ Release System

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

At the Orthopedic Technology and Innovation Forum, Matthew T. Provencher, MD (Vail, CO), presents a discussion on surgical reconstruction options for glenoid bone loss, highlighting modern algorithms for autograft and allograft fixation.

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Autograft and Allograft Fixation Options for Glenoid Bone Loss

OrthoPedia: Autograft and Allograft Fixation Options for Glenoid Bone Loss

Carl T. Hasselman, MD (Pittsburgh, PA), demonstrates the effectiveness of the ApolloRF® SJ50 probe in various ankle procedures. Dr. Hasselman highlights the probe’s benefits, including low default settings, optimized aspiration, and 50° curvature.

ApolloRF® SJ50 Probe in Ankle Arthroscopy

Hi, I'm Doctor Carl Hausmann. I'm from the University of Pittsburgh in Pittsburgh, Pennsylvania. What we're going to do is we're going to go over ankle arthroscopy with the use of the Arthrex S-50 Apollo probe. So I put my curve, the tip of my probe, 90 degrees into the joint. And then I lift my hand and it just goes in very quickly and easily. And that keeps you from struggling with the probe. Because once the probe is in, it will do the work for you. It also has hand control. So you'll have blue, which is just like on most instruments. It's going to be your coagulation and you're going to have yellow which will be kind of your cut and rapid cut. It comes with factory settings. I can tell you right now, 98% of the time the factory settings are more than enough to accomplish everything I need to do. But the nice thing is, is you can actually increase or decrease the intensities from the factory setting on the probes. With this probe at the factory setting, it really takes a matter of a second, and you can get a lot of this tissue out of the way. The neat thing about this is you'll notice it has the suction, so that if I do get an air bubble or two, it quite quickly alleviates them. And that's what I like about this probe more than the others. And so the nice thing is this thing is keeping the area cool while I'm doing my ablation of that area. Most probes, as they're straight when they come in, that's what you're going to get. So you're going to actually have to take your hand and bend your probe. And most of the probes are too stiff. So you end up using a pair of pliers or something to bend it. Then you ruin the sheath on the probe. You end up throwing them away. This probe has that hook so you literally can come in. And then when you rotate it, actually look at that. It matches the shape of the talus. So it is designed to let you go back all the way to the back of the ankle. And you can see I am literally basically almost at Subtalar joint. I'm so far back in the ankle. In fact, there's the posterior tibiofibular ligament. And you can see this probe can get all the way down to the posterior part of the ankle. So if you're trying to get an Ars trigonum out arthroscopically, I am literally right where the eyes would sit. So you could actually do your complete synovectomy with this probe and you can get all the way back. The other beauty is that two things of this probe, it actually has a 360 degree cutting edge on it, which is quite nice because you can actually use the edges just as much as the surface to do ablation. So one of the things you can watch is if for some reason you wanted to take down one of the ligaments in the back, I can literally put it in there and I can actually just hit and you can see that it's starting to actually cut using the edge of the probe. And you can see how I'm already starting. I'll go in close. You can see how the edge is literally cutting the ligament for me. But at the same time, if I didn't want to cut the ligament, say it was just hypertrophied and thick and frayed. I can also use my COAG. And if you watch when I see these frayed edges, I can literally just use my COAG and it will just get rid of the frayed edges. So it's basically getting rid of those frayed edges without really damaging the fibers, because you can see the see the fibers are still not hurting or not being damaged. They're staying perfectly nice. Now, for example, in arthritis, a lot of times we all see this shag carpet appearance and you want to get rid of this, but you can literally take this probe, putting it on COAG and just kind of come in and clean those areas up and see how I can just nicely get rid of that shag carpeting by kind of just mowing along it. But if you look down at the cartilage, you'll notice that I really haven't damaged the cartilage in any way. My probe is now between the anterior capsule of the ankle and the anterior edge of the tibia. And very commonly, we want to get rid of all the synovitis if we're doing an anterior colectomy. And so the beauty of this probe is you can actually get right up in that area. And then with my probe on cut, I can literally clean this whole area up. The one thing I have found is that a lot of times I'll give it a second breath after about 5 or 6 seconds, I'll like take a one second just to let the aspiration get rid of any warm fluid. And that way I can keep the whole joint space nice and Nice and cool. So I'm at the anteromedial gutter of the ankle. There's going to be some fibers of the anterior deltoid that I can clean out. But you can see, I can rapidly clean out all of the tissue in the anteromedial ankle. And the other nice thing about the probe is when I'm in here with this probe is because it's hooked. One of the other things I can actually use is use the hook to my benefit. So I can actually come in, and I can hook that tissue and pull it away from the cartilage surface. And once I have it pulled away from the cartilage surface, then I can hit my cut and I can actually cut the tissue. And that way I'm really staying away from my articular area so the hook actually can use it as an advantage, just like a nerve hook to get rid of this tissue. If you're getting nervous that you're getting a little too close. Now, what I could do is if I wanted to get rid of this, I could literally use my probe because of that hook, and I could breed all the tissue around it quite quickly. The nice thing is, I can respect that cutting of the 360 cutting. You'll notice how I'm literally taking off this tissue right around it, and not a single bit of damage to the lateral wall or the medial wall of the talus. And so I can ablate this. And I can also use the hook action to pull it away in a blade. And you can actually see how I've completely loosened this. So the neat thing is, is I've done a complete using the Sf50 probe. And now I'm just going to use one of the Arthrex Graspers. And I can come in and literally grab that piece. And the thing is I can pull it out. And now there's just a small piece left. And I'm not going to belabor the point, but you can see how easily I did that. But the really neat thing is with that probe is I just put this in and I'll pull the tissue back and we'll look. You do not see any damage. We did a complete synovectomy and Dyneema of the medial gutter. And there's not a single burn mark, not a scuff mark, not a single mark on that talus showing you that the probe didn't hurt the articular cartilage in any way, shape or form. And that's really neat about this because you literally just took out all that synovitis, and there's just a small piece of that medial malleolus left. This person has a cartilage lesion and it's an anterior lateral OCD, which is not uncommon. So a lot of times after we've done our microfracture, a lot of times we'll have those edges. This is the other place the ss50. So now you've microfracture you're quite happy. But you'll notice one of the things that we have left now is we have this rough edges right in here, and we worry about those breaking off. A lot of times people will put a shaver in, but this is actually one of my favorite tricks, is you can actually bring the ss50 in. And with the COAG just slowly, gently hit these areas and it actually kind of just takes off any of the rough edges. So just using the probe and little blasts, I can clean up any of those rough edges. But I'm not hurting the cartilage. Some of the key tricks to remember one. When you're inserting it, always insert the probe so probe so that the tip goes in first at a 90 degree. So you notice how my hand is held. So I'm going in first. Then I rotate my hand. Don't try to go straight in. It's not going to work because unless you want to make huge incisions it's not going to work. You want to keep your incision small, put the probe in, get into just the edge of the capsule, then rotate your hand. It comes in quite quickly. Number two respect the curve. Remember, when you're going back into the back of the ankle, you have to keep it turned at a 90 degree only as it goes past the talus. Then I rotate it and it respects it. And so now I can go into the back of the ankle and I'm in the back of the ankle. I can do all my work. And that actually is the safety probe and a lot of things I like about it. Again, I have that COAG function works great for osteochondral lesions, and you'll ablate it within a matter of seconds. And it's beautiful. It saves you a lot of time. And that's kind of the reasons, all the reasons that I like this probe because it has all the functions you could possibly need.

ApolloRF® SJ50 probe in Ankle Arthroscopy

Sohrab Gollogly, MD (Monterey, CA), demonstrates the transforaminal epidural steroid injection technique for the endoscopist who wishes to use the same technique for targeting and localization of transforaminal endoscopic spine procedures.

Transforaminal Epidural Steroid Injection for the Endoscopic Spine Surgeon

My name is Saurabh Gallegly. I'm an orthopedic spine surgeon in Monterey, California. I specialize in endoscopic spinal procedures, and today I'm going to demonstrate the transforaminal epidural steroid injection technique that I use for the Endoscopist, who wishes to use the same exact technique for targeting and localization of transforaminal endoscopic procedures. We're going to begin with the patient in the prone position on the operative table. We'll take an orthogonal AP X-ray with a radiopaque marker across the intended disc space, and will align that marker with the midline of the disc space as seen there of the L4 five level. We'll draw that line on the skin and then we'll swing to the lateral projection. Once we've moved the fluoroscopy unit from the AP to the lateral plane, we will align the fluoroscopy unit by imagining a line from the center of the source, coincident with the line drawn on the skin to the center of the detector unit. We'll take a lateral x ray, and that generally corresponds with a perfectly aligned orthogonal lateral x ray of the disc space in question, centered in the center of the fluoroscopy field of view. And next we'll find our starting position by compressing the skin on the patient's flank, identifying a spot Art as seen here, where the tip of the radiopaque marker is two facet widths posterior to the facet complex in line with, in this case, the l45 disk space, and that generally corresponds to a distance of 10 to 12cm from the midline, depending upon the sex, stature, and shape of the patient. After identifying the starting point, we'll appropriately prep the skin with a chlorhexidine or alcohol prep. We'll use a small amount of local anesthetic in order to raise a wheel in the skin. After the skin is appropriately anesthetized, we'll introduce a spinal needle in the starting trajectory, and after puncturing through the skin, we'll follow the same line drawn on the skin, using the fluoroscopy as a reference mark in a slightly more shallow angle than anticipated, until we dock on the lateral aspect of the complex as seen there. That fluoroscopy picture shows that this spinal needle is on the dorsal lateral aspect of the facet. So we'll back the needle up and we'll raise our hand in order to go more ventral on the facet picture there. We're now at the midpoint of the facet joint and lined with the disc space. We'll back up a little bit more. Go a little bit more. Ventral here. Picture there. Just about through here to the disc space. One more slight raise of the hand here. Picture there. And we're in the foraminal space. The tactile feel that confirms that you're in the correct location is you'll feel a slight pop as you skive off the facet joint through the facet capsule into the foraminal location. And as we swing to an AP view, now we can confirm that the tip of the spinal needle that we are indeed just lateral to the mid line in the real world, the needle is now safely positioned in Camden's triangle. The traversing nerve root is medial to the tip of the needle. The exiting nerve root is superior to the tip of the needle. And if we were to inject a CC or two of the appropriate steroid plus local anesthetic, we would get a transforaminal epidural steroid injection in the exact same position that we would introduce the endoscope. In this instance, for demonstration purposes, we're going to inject a CC or two of Omniview in order to outline the traversing and exiting nerve roots, and demonstrate the placement of the tip of the needle.

Transforaminal Epidural Steroid Injection for the Endoscopic Spine Surgeon

This animation highlights various features and clinical applications of the ApolloRF® SJ50 probe, the first probe for foot and ankle arthroscopy with optimized fluid management for debris and bubble control.

ApolloRF® SJ50 Probe

ApolloRF® SJ50 Probe

ShARC celebrates a standout year with 10 new publications (over 90 since 2015), more than five papers under journal review, and major visibility at meetings like ASES, Pinnacle, and the inaugural ShARC ATAC in Munich. The number of followers we have on LinkedIn has surged. We launched the first-ever ShARC Report and introduced a wave of ShARC Bites, setting the stage for our panelists to dive into the momentum behind this incredible year.

ShARC 2025 Year in Review

Welcome to the Shark Tank. For those of you that aren't familiar with shark, shark is the Shoulder Arthroplasty Research Committee, and this is an arthrex supported but surgeon driven research group that has some really exciting stuff going on for the past ten years. What we want to spend today doing is summarizing 2025. And so in 2025, the shark group had ten peer reviewed publications. That's over 90 total. Now. Since 2015, we've had more than five publications currently submitted and under review at a journal. We have more than 3000 followers on. The new shark LinkedIn page also has a new exciting thing called Shark Bites. And we'll get into those a little bit later. We have ten Shark Bites published with three additional that should be published by the end of the year. But today, our focus is going to be to review some of the key research in 2025. So today with me, I have Evan Lederman and Pat Dennard. We're going to discuss some of our favorite studies from 2025. So the first time we're going to talk about really focuses on sphere size and base plate retroversion in reverse shoulder arthroplasty. So Pat, tell me a little bit about some of the important findings of this study. Yeah, this work is really important. And I've seen a shift in my practice the last couple of years dropping my Glenn sphere size. So we did a couple of studies. First, we looked at axillary radiographs and then scapular y radiographs and showed that the distance to the coracoid is important. The further you are away the better outcomes you have particularly with internal rotation. So here we looked at 3D environment. People had plans placed with Sci. So implant position was secured. And we found that a smaller Glenn sphere actually improved internal rotation. For every millimeter drop, you had a 0.5 increase in spinal internal rotation behind the back. Said another way, if you go from a 36 to a 33, you get about 1.5 levels of increased internal rotation. We also found that the further you are away from the coracoid, your aches scores go up and your internal rotation goes up. So now I'm doing about 48% 33mm in my practice, which is a shift over time dropping in size. Yeah, I think that really highlights what's really exciting about some of the arthroplasty research that we're bringing out of the Shark Committee. It's that it's really clinically relevant and helps us really personalize our treatment for each individual patient. Evan, how has this impacted your practice? Yeah, I agree with Pat. This has had a very significant impact on my practice. So historically we use larger glenoid spheres for stability and what we thought was better range of motion. But anterior shoulder pain and decreased internal rotation has been a problem all along. By downsizing the glenoid sphere and moving it a little bit more away from the coracoid, I see less anterior shoulder pain in my patients post-operatively. And we're seeing improved internal rotation, which is supported by literature. So this has been a trend that I think we're going to learn a whole lot more about over time. That's definitely shifted me to a smaller glacier. I completely agree. Same things happened in my practice. All right, so we'll move on next. Our next study is looking at glenoid sited lateralization and scapular notching with our reverse arthroplasty. So Evan, why don't you tell us a little bit about that study. So scapular notching originally was thought to not be a big problem. But we've seen over the years that scapular notching leads to decreased patient satisfaction, decreased scores, pain loosening, osteolysis. And this is a body of work that's been going on for a while. Looking at how to reduce scapular notching, we identified moving from a 155 implant to a 135 implant, dramatically decreased scapular notching, and we published another paper through shark that showed four millimetres of lateralization, further decreased it by a little bit. But now that we have more ability to lateralize the glenoid side within our system out to eight millimetres, we've identified that we can further decrease scapular notching by lateralizing six millimetres or more specifically six millimetres in women and eight millimetres in men, probably because men are a little bit bigger. We also identified that if we infused the salt overhangs a little bit, which is not a new concept that's been there for a long time, but that also decreases the scapular notching, improves the Asca scores, and improves range of motion in all planes. So our goal is lateralization six millimetres in women, eight millimetres in men, one millimeter or so of inferior overhang. And now multiple studies have shown that to improve our results overall. And I completely agree. And lateralization has been a little bit of a learning curve for me. And switching from a previous system over to Arthrex system, I think this also really shows what we're really able to do out of the research group is we're really able to take these surgeon driven questions that are really important to us and be able to get research behind them, and then apply them to clinical practice. Any final thoughts on that study? Pat, I think Evan hit it. It's the six in women, eight in men, and really thinking about the individualized approach that you can use with all these options we have from size to lateralization. And so it's great to have such a large portfolio. And now the research behind it, to be able to understand how to personalize it for each individual patient. So move on. Next to a study that I just wanted to to talk about a little bit. I found it to be very helpful for my clinical practice. This was looking at the results of eclipse in patients over the age of 70, when eclipse came available in the market, was very excited about it and able to use it, but I'd done my entire training in early part of my practice with the Stem, as I'm sure all of you did as well. And so I was a little bit worried about is there an age cutoff? Is there a patient who's too old to get a stem implant? And so a couple of key findings from this. Number one, at two years after surgery, x rays and patient reported outcomes were very good in the older patients and comparable to the patients at least x ray wise who were the younger patients. So the older patients had just as well patient reported outcomes were actually better in the older patients. I found that to be interesting because I was following this trend of older patients getting reverses. And there probably is a select group of older patients that do well with anatomic. And then the final thing that I think is an important discussion point is that Jesus made us put the word arthrex eclipse. So put the brand in the title. And I used to try to be implant agnostic in the titles when I would publish, but I think that's kind of an important trend that Jesus is doing. So I wanted to turn this over to you, Pat. Thoughts on any of these points, the older patients, the specific specificity of these findings to eclipse? Well, the title thing, you know, they're requiring that because the implants are different, right. Most stemless implants are metaphyseal impaction. So we know if you look at that data, about 8% of the time people have to convert. And with eclipse you're getting cortical support and rim compression. So it's just a much more robust implant. And we're seeing that in these older patients. You can indeed use a stemless implant with eclipse which gives you all the wonderful benefits of stemless with restoration of center of rotation etc. less pain. All of that, but it's really specific to this implant. And if you are in the position where the bone quality is so poor that you're you're concerned, you're probably at the point of reverse in that case, because you've really reached the limits of what a stemless can do. Completely agree. Evan, any final thoughts on that study? How has your practice shifted in terms of older patients use of stemless, and how do you see that change in the future? So the indication for anatomic shoulder replacement doesn't change. But the ability to use the stemless implant has allowed us to decrease post-operative pain, which we've shown in another study, get better anatomic restoration, which ideally is going to lead to less subscapularis failure in the future. But in the if we do have a subscapularis failure, revising a stemless implant is far simpler than revising a stemmed implant. And the the time to revise the stemless implant is less than it is for stemmed implant or even a convertible implant in many cases. So I moved also to to stemless almost entirely in my practice. But it hasn't changed who I do it in. The indications are still the same. Completely agree. All right. So we'll move on to our next day. And this is one that I'm really excited about. This was a study looking at glenoid lateralization. And how do we individualize that for certain scapular neck lengths. And this utilizes what's called a statistical shape model. So Pat maybe just take us a little bit through what a statistical shape model is, a little bit of the findings of this study. And then importantly, how we can use statistical shape model going forward with research and clinical practice. Right. So there's a large amount of variability in anatomy. We kind of talked about size earlier. And now what we're seeing here is when we take a large database that we have with the VIP patients and and look at the different shapes, whether it's controlling scapular size or in this case, looking at scapular neck length, you're seeing variability. And what we're really trying to move toward is an individualized reverse. And I think you're going to increasingly see technology like this come into play in our planning where we can say in this particular patient, I want to use this amount of lateralization in this position to really optimize the outcome as we go forward. Yeah, and I think there's just a lot of things the statistical shape model can do that we just don't have the ability or the time to compute all those variables critical shoulder angle, scapular size, scapular neck length, scapular neck angle and be able to help figure out how to optimize and pick the exact implants that we choose for that patient. And so I think it would be a really exciting thing that we see one of the other big things. I don't know, Evan, if you have some thoughts on this as well, but the the statistical shape model can predict the Premorbid joint line. Any thoughts on that at all? So honestly, I think that's the most important thing that the statistical shape model is going to do. This is work that Joey and I started years ago with the vault model looking at where was the actual premorbid anatomy. And I think when we truly understand that, then we're going to have consistency in what our lateralization inclination version angles are right now, we're very reactive to what we see in the eroded arthritic glenoid, but that allow us to do it off of the premorbid glenoid, which I think will be a game changer once it becomes usable at everyday. And so stay tuned for statistical shape modeling. This is something you're going to see pervasive in our future research, but also in implant design, choosing implant sizes, and then also in VIP to help more accurately predict what implants each patient needs. So we'll move on next, shift gears a little bit to shark bites. And so for those of you that aren't familiar with shark bites, shark bites are consensus statements that are really designed to answer common clinical questions that surgeons have every single day, whether they're indicating patients for arthroplasty, planning the surgery, intraoperatively trying to execute the case, or rehabilitating patients Post-operatively. The goal of these is to make that seamless and easier, and the result of kind of the consensus of the shark group. So each shark bite introduces the topic. It then provides a summary recommendation. It includes relevant data from the shark registry or relative shark Publications, and then also the consensus input from the entire 40 person Shark Committee on that topic. So today we're going to talk about two different shark consensus statements or shark bites. The first one we're going to talk a little bit about is glenoid lateralization or reverse shoulder arthroplasty. So Evan take that one away. So the real value of the shark bite is for the orthopedic surgeon who doesn't want to read all the literature, but wants to be able to achieve the results that we do. So they're a nice consensus statement that kind of summarizes it all for the use. So when we're looking at lateralization, we want to avoid medialization of the implant. We need to restore the lateral tension on the rotator cuff. And as stated in the study earlier, we want to lateralize men eight millimetres, women six millimetres. And this is a consensus not only based on that literature, but on the utilization of the 40 contributing surgeons to it. So reading through this gives surgeon good guidance on how to lateralize. And again, for those of you that aren't familiar with them, these are all available on the website. Easy to download and truly beneficial for reps arthroplasty managers, surgeons who are early in practice, surgeons who are changing their practice over from a different implant. And it gives you a good consensus of what surgeons who do these implants at a very high volume can do. So we'll move on next. There's another interesting shark bite on glenoid inclination and anatomic total shoulder. So Pat, why don't you summarize that one. Yeah. So in the past much of the focus has been on version. And we're increasingly looking at inclination as an important variable in outcomes not only in reverse but also anatomic arthroplasty. We know biomechanically. If you have a little inferior tilt that's probably beneficial. And clinically, we did a study a couple of years ago showing that two degrees of correction improved functional outcomes at two years. So this consensus statement, what we see is that most of the time, about 61% of the time our surgeons recommend matching anatomy, but in actually 40% actually aim for a little bit inferior tilt based on that study. And I think what's most important though is that there's this balance. If you're going to get inferior tilt, you're going to have to ream a little bit. And 96% of the surgeons recommend reaming three millimeters or less to preserve subchondral bone. And this is really where technology such as depth of ream comes into play, because now we can control pin position version inclination with VIP and the Targeter, but also control depth, how far you go in and ream so that you can get a little correction, but preserve the subchondral bone for your long term outcome. Completely agree, and I think it's just another demonstration of how important the research group is, how important the partnership with Arthrex is, and being able to answer these clinical questions, but then also provide this data so that all surgeons can be operating at a really high level, regardless of the volume that they're doing. So thanks, everyone for joining us. The I think what you're going to see from this discussion today and overall, is that the Shoulder Arthroplasty Research Committee has really emerged as a leader in shoulder arthroplasty research. It's key that we have the support of Arthrex to be able to continue these initiatives, but it's really a surgeon driven group that continues to produce meaningful clinical literature and also influences the clinical practice of shoulder arthroplasty. The shark bites have been a great addition over the past year. I think these are really helpful again for surgeons, for early surgeons, later surgeons who are changing over implants, but also arthroplasty managers and reps to really understand, in a succinct form what we're doing as surgeons and how that can help patients. And finally, stay tuned. You know, we're very present on social media. We're at every major meeting on the podium. You see publications in all the major shoulder arthroplasty journals, from the Shoulder Arthroplasty Research Committee, and every arthrex shoulder arthroplasty course is going to have the shark literature showing at it. And so stay tuned to shark. We're going to continue to help shape the future of shoulder arthroplasty. Thanks, Evan. Thanks, Pat, for joining me. Thank you Brian.

ShARC 2025 Year in Review

Kevin Martin, DO (Columbus, OH), reviews his technique for the stabilization of the syndesmosis in his most demanding patients. Using the Syndesmosis TightRope® repair, InternalBrace™ ligament augmentation, and NanoScope™ arthroscopy, he is able to confidently and anatomically repair the syndesmosis via a minimally invasive technique.&nbsp;
 
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.

All-Inside Arthroscopic Syndesmosis Repair

Hi, my name is Doctor Kevin Martin. I'm an orthopedic foot and ankle surgeon from the Ohio State University. In dealing with these high ankle sprains and athletes, we first begin by looking at the high ankle sprain with a nano. We identify the torn ligaments and we identify the instability. After that we reduce it anatomically and start with our XP stabilization with a tightrope. We then work our way distally, and then we augment with the internal brace across the front of the atfl, giving us two points of fixation and getting our athletes back on the field sooner. All right, so the first thing we do when we start to diagnose our athletes with a high ankle sprain is we perform a diagnostic arthroscopy. I utilize nano, and we can be able to look around inside the ankle and clearly visualize the anatomic structures coming over here to the syndesmosis. We use a small joint probe and we're able to evaluate the fibula here distal tibia and of course the talus here. We start to see in this patient that the AI TfL is attenuated. It's torn here and up here. So this would back up our diagnostic examination. We could also do a fibular translation test, where we try to translate the fibula anterior to posteriorly, and we can also stick a small probe into our syndesmosis here, and truly do a good diagnostic examination and see if our ankle is unstable to a dynamic examination. All right. So now the next most important part is we switch portals and we do a direct visualization into the syndesmosis. We can see our talus on the left side of the screen. Our tibia on the top and our fibula. And so we want to do is restore and evaluate the Mercedes sign. This is an anatomic reduction of the syndesmosis. And this really allows our surgeons to be able to look and evaluate if the syndesmosis is truly reduced. This is the view that needs to be visualized and identified before and after the reconstruction is done. And it doesn't get much better than that. Nanovision straightforward viewing allows you to look directly into the syndesmosis without any obstructed view. Okay, once we have our diagnostic arthroscopy complete, we use fluoro to identify where we feel the tightrope should be placed proximal to the joint line, but yet within the incisura. So we place our guide wire, make a small percutaneous incision. And that's how we get our athletes back so much faster by just doing a very small percutaneous incision. And then under Fluoroscopic guidance, we'll take our arthrex synergy system. And we'll drive this wire across the syndesmosis and out, dropping our hand approximately 30 degrees to get the proper angle. All right. So now we're going to use our new synergy power system to drill across the Syndesmosis follows the guidewire very nicely across four cortices. You want to make sure you feel that nice pop along that medial cortex, but not to plunge through the periosteum. We want to keep that periosteum intact, to act as a trampoline, to stop our tightrope button. Now that we've drilled, we'll take our Arthrex XP and we'll have the red button facing us. We'll pull our guidewire out and follow directly behind it with the button and we go through. We'll just have a gentle rotation, not too much and we'll slide it across. When you feel it on your other contralateral side, you can take a small fluoro shot and ensure that you're through. Feel it. Then take our red tab, we'll pull our red tab off and we'll pull back on our button. This releases the button medially and we can see our fluoroscopic change as well. So now we've demonstrated that the button is disengaged and along the far cortex. At this point our handle can be removed. And then we'll take and we'll slowly pull down. Sometimes I manipulate the soft tissue on the inside of the ankle pulling it. You can feel the buttons slide down nicely as you add tension across it. And then we've laid the button directly on the cortex. Very nice. Now, looking laterally, the way we can do this, we pull and we slide the button down. What I like to do is slide it down first like this and hold it as we slide this down. What that does is it prevents any looping or tangles along the suture. So we slide this down very nicely like that. And what we do is now we pull them side to side evenly, ensuring there's no loops or tangles back and forth very slowly, making sure that you pull the same angle you drilled. And we'll secure that button directly on the cortex. Okay, so after we've pulled our button down under the skin, we then attach our blue handles. Attaching the blue handles relatively close allows you to better control. And then we sequentially tighten them one at a time and we pull in the same direction we drilled. So we pull. You can feel some of that creep come out of the sutures, and we simply switch to the other one and again pull in the same in-line direction. You can really feel the tension coming out of the system. You can really feel that knot snugging down, and we go back and forth until we feel we've got enough. I leave these on, and then at that point I can repeat my stress examination to evaluate the syndesmosis if you need to apply a little bit more tension, but usually that's enough. All right. So after the tight rope is placed we then repeat our examination again. Repeat a dynamic stress examination. And for our higher demand athletes we're going to do is a second point of fixation. Because he's higher demand athletes require that. So I'm looking at the syndesmosis and I'm looking at the TfL insertion on the fibula here and its insertion up here on the distal tibia. So what we're going to do is reconstruct the AI TfL using internal brace. Okay. Now we'll directly visualize the insertion of the TfL on the distal tibia. We'll take nano. We'll pull back, we'll visualize the footprint and we'll drive right into the footprint and secure it to the distal tibia. Then what we can do is we can pull back gently, and we can actually look through Nano and ensure that that footprint is right where we want it. So once we get that we like our angle, we can change it. We can confirm under fluoroscopy and we can pull that back. And it's important to hold that same angle. And now your guidewire that comes in the IB kit will go straight down that sheath. And we can advance it under power all arthroscopic. Now we can pull that out. Very safe. You've protected the superficial peroneal nerve completely during that whole procedure, so it's for safe keeping. Then we can come back in and we can visualize the guide wires placement and confirm its position. All right. Once the guidewire is in place, I then put the drill guide directly over our wire. Again, we're protecting the superficial peroneal nerve, and we slide it down our guidewire and then press it, press it directly onto the cortical surface. Once we have it in place and we confirmed arthroscopically, we can now drill with our cannulated drill bit. Again, safety is paramount here by protecting the superficial peroneal nerve and doing it all under direct arthroscopic visualization. As we drill, it has a hard stop. So we'll drill until our hard stop and then we're done. So now what we've done, we've drilled. We've got our drill guide in there still. And now we'll slide our cannulated, tap directly down our guidewire and we can tap all arthroscopically. All right. So now you take the tap all the way down the guidewire. It comes with a nice black line right here. You can tap and you can watch the black line come right down to where you want it to be. And that way again arthroscopically you can see exactly how far you want to tap. It's usually right about there. And there we go. Now we've drilled and tapped all with our cannulated system, and the tap simply comes out and the guidewire will come out with it too at this point. Very good. If you want to confirm, you can change portals and we can look directly into our. This is where the beautiful component of nano. If you want to confirm your placement, you can actually see the threads we've now cut with a fine detail that nano can provide. Sometimes we use little sx50, and we can take the little RF, and we can actually prepare the point of the fibula right where we're going to put our tunnel, and where we're going to put our anchor. That allows for better visualization and really preps the bone to prevent any soft tissue bridging you may have. We can then place nano back in their anterior lateral portal and visualize that footprint completely again, taking nano and pushing it directly into the fibula. Pull back. We can directly visualize we have nice bony opposition. If you still want to adjust it, you can still place your camera back in. You can verify there's the Mercedes sign. We come right over to the fibula. That spot we prepared already with our RF ablator, and now we can hold it. We can pull nano out again, confirming our view, and then use nano as a drill guide and allows perfect arthroscopic targeted screw placement. Now you can confirm that you have a direct anatomic location of your guidewire directly on the fibula at the footprint of the AI TfL. We can then slide our drill guide directly down onto the fibula and confirm position. Once we're down on the bone, we then can drill with our cannulated drill bit and it's got a hard stop, so we'll go until it stops. Excellent. Good job. All right. And we don't need to tap down here. So we are confirmed and we like our placement. Okay. All right. Now that we have drilled and tapped all arthroscopically, we then take our 4.75mm swivel lock with the internal brace already loaded, and we can directly place it into the hole we've already drilled and tapped. And we'll place this in. We'll give it a few gentle mallets to get the anchor down. Now we'll hold the square and turn the pair, and we can directly visualize that anchor going in again. Nano gives you a beautiful view of that. Going right in. Excellent. Now we can stop there and we can unload the anchor. All right. We can back this off if we want to confirm our placement. And we can see here that the anchor is in, we can give it a couple more turns. We have plenty of space in the distal tibia. And then we can simply remove our device prior to placing the 3.5mm anchor. You can then take a small probe if you'd like to, to ensure you have the right trajectory, and kind of get the feel of where your anchor is going to go. And you can also spin this and confirm you have good osseous opposition around the anchor. In case you're concerned that you may have missed the fibula or don't have it center center. Now we'll take our 3.5mm anchor and walk it over to our our hole we've drilled and that will gently mount it into position. Go ahead. Once we get the anchor just barely seated, we then hold the square and turn the pair, and again we can watch the anchor go under. Direct arthroscopic visualization gives that nice squeak, giving us good confirmation. We have a very nice fixation. And again, it's a beautiful visualization right down that beautiful arthritic squeak we all love. And we can back off our our entry guide and really confirm that we have nice placement here of our anchor. A couple more turns to make sure it's recessed and then pull it out. Once we have that out, we can then switch and visualize. Now we can confirm our placement of our 4.75 and the distal tibia. We confirm our confirm our 3.5mm and our fibula. And then we really like to do is get a dynamic examination. So really take the ankle through a range of motion, really confirm that you have the Mercedes sign. And look at that Syndesmosis now we can see it's closed down. We're anatomic. We can really see that Mercedes sign right there. Now we have two points of fixation, all arthroscopic and very anatomic. We could put our anchor a little bit more proximal here if you'd like. Regardless though you get the idea. And we get two points of fixation through three small incisions again, giving our bigger athletes a more higher demand, athletes an ability to get back on the field sooner with two points of fixation. Okay, we can then slide down an arthroscopic cutter right above our knot and cut and release, then change portals once again and allows you to directly visualize the repair we just completed. Beautiful. You can see our distal fibula here, distal tibia here. And now we have an anatomic reconstruction. And we can see our syndesmosis right here is completely restored. We have that good Mercedes sign right there. And we do a dynamic examination ensuring that it's stable. We can do a dorsiflexion external rotation stress test here as well. So now we have two points of fixation. The internal brace was placed proximal to center and the incisura. And our second is placed anatomically to reconstruct and augment the TfL.

All-Inside Arthroscopic Syndesmosis Repair

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

Distal Biceps Tendon Repair Using the TensionTight™ Button

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

Distal Biceps Tendon Repair Using the TensionTight™ Button

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

All-Suture Implant Techniques in Ligament Reconstruction

Orthopedia: All-Suture Implant Techniques in Ligament Reconstruction

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

Mini Fragment System Animation

Mini Fragment System Animation

The revolutionary TightRope SB™ implant eliminates metal hardware from ACL reconstruction procedures and features a suture-based button for cortical fixation. This animation demonstrates a QuadLink™ ACL reconstruction using the FiberTag® TightRope® SB implant with the InternalBrace™ technique.
The InternalBrace surgical technique is intended only to augment the primary repair/reconstruction by expanding the area of tissue approximation during the healing period and is not intended as a replacement for the native ligament. The InternalBrace technique is for use during soft tissue-to-bone fixation procedures and is not cleared for bone-to-bone fixation.

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

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

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

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

Achilles Midsubstance SpeedBridge™ Surgical Technique

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

Achilles Midsubstance SpeedBridge™ Surgical Technique

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

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

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

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

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