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Gregory S. DiFelice, MD (New York, NY), presents alternatives in multiligament treatment.

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Alternatives in Multiligament Treatment

I've been coming to Arthrex probably since I think 2003. And I practiced when I originally came out. I practiced in a, in an urban level one trauma center, and I saw much the same cases that were just presented to you. And the evolution of my thought came along. And it's interesting how you listen to all the different perspectives, because it's really the evolution of thought is the same as we all start questioning the previous generation's conclusions. And this is the place where I worked, I'm convinced that a lot of the old experience say, for example, with the MCL, the previous generation was was burned in repairing the MCL for one reason alone is because they put the patient in a cast for two months after they did the surgery. And everybody knows if you put a if you cast someone for a long period of time, it's kind of like imagining do a total knee and then put them in a cast at 20 degrees for two months and then tell me how they're going to do. It's so it's really moving the patients. It's all these little things. And I really have to thank Reinhold and Arthrex for continually innovating and coming up with a new ways of doing it that minimize things and, and allow us to really kind of evolve our surgical thought. So I started off with and I learned a lot of things about multi legs. And one was that you need to get to them quickly, or else things that are neglected like this will turn into that. And this is kind of this was one of the pictures from way back when, when I was doing multi legs in the early 2000. And there's hardware everywhere. There's a lot of different ways to do it, but really kind of the thought was to reconstruct everything early. We talk a lot about failure, but we don't talk a lot about the morbidity of the procedure. And anyone who does a lot of multi legs knows that you're going to get stiffness, you're going to get recurrent PCL sag. You're going to have to go back and re-operate to do lysis of adhesions. And these are the things that make people avoid these multi legs. And so I went from this. And then my my techniques evolved as, as the RetroCutter came through and things and I could minimize the surgical insult. And this is A1I think one of the first all-inside multi legs that was presented. And then it started to evolve to try and minimize the surgery even more. And when I would see this type of dislocation with, with ACLs and Pcls that were literally popped right off the bone, I started trying to repair them like I talked about in the in the ACL repair talk. And so the benefits of repair in the multi leg are in what I use is a ligament preservation approach. I explained to my patients essentially, look, I'm going to go in and try and repair what I can. If I can't repair it, I'm going to try and repair as much as I can and add a graph to it to keep the biology. And if I can't, then I'm going to use reconstruction as a last resort. So it's a stepwise approach. I call it ligament preservation. I think early intervention in these things is tremendously important, and the literature bears that out. A repair or this preservation approach decreases the morbidity, decreases the stiffness. And the InternalBrace technology has really led to, you know, a lot of windows opening in this in this old haunted house of the multi ligament knee. It maintains the natural biology, proprioception and anatomy. And it doesn't burn bridges if you have a repair. I call it damage control orthopedics. If you have one of these horrifically injured knees, sometimes you can sneak in there, tack a few things back into place. You can always come back to fight another day and some. A lot of times you'll find out that everything heals up anyways. You don't even have to come back. So my question is always, should we be looking for home runs in the treatment of these horrific injuries, or should we be just trying to get base hits? Should we just trying to make things better? And in a stepwise fashion, do we all have to do it? Do we have to do it all right at the first go around? So this is one of my first papers. I actually started with my repair evolution and journey. I actually started repairing the PCL. And I'll give the credit to Doctor Warren at HSS, who used who taught me when I was a resident that sometimes the PCL pops right off the bone, and he would put some stitches in it and just pull it back. Well, as the rotator cuff technology and the anchors and the stitches came out and they started getting better and better, I would go into these knees and I started to stitch the PCL back first. And this is the first paper I ever published talking about PCL repairs. So if I had a repair like this with a proximal tear off the bone on the sagittal and the coronal, this is what it looks like. It's there. Always kind of sagged back because as the tibia sags posteriorly, it drags that proximally torn PCL with it. And then you have to reduce the piece, the tibia to see if the PCL is going to reach. And here you can see me with my grasper pulling the PCL up. A lot of times people will go in and grab it, pull and say it's not going to make it. It's because you're not reducing the tibial sag, and it gives you this kind of erroneous thought that the PCL won't reach. Put some stitches in it. And this is real. This is old stuff. Some of you have been around for a while. You might recognize this is the the RetroCutter drill. That was the only Cannulated drill way back when. And so we put that in and and tie that PCL up nicely. Well this is six year post-op MRI. You can see it's healed up nicely. Well eventually that evolved to PCL with internal brace. And that's a little trickier. And as you do more of these you have to get to the back of the knee like was shown with that Posteromedial portal is incredibly helpful. And this one is very similar. Here I am reducing it. This is the opposite leg. So it's everything's reversed. We're reducing it to see if it will reach. And we've got the stitches in it. We're pulling it up. And again we've got at this point I'm using suture anchors. And you can see that top anchor. I've got the TigerTape in there. And now I'm going to, I've drilled a hole up through my tibia and I've got a passing suture. And I'm going to pull that TigerTape down along the back of the PCL and through the tibia, just just like I would pull the ACL repair along the front of the ACL. Now this is looking at it from a front internally braced ACL and PCL primary repairs. And this is looking at it from the back. You're looking from a Posteromedial portal. And you can see that TigerTape and the body of the PCL and the TigerTape is running along the posterior aspect of the PCL there and then down through the tibia to reinforce it. Sometimes you have a PCL avulsion fractures. You can treat these just like McKeever fractures for the ACL. It's a little trickier. You have to take down the posterior veil of tissue behind the PCL. But you can get in on these, pull them down and tie them over a button. Sometimes I'll even I'll put a button on the inside too. I'll put my FiberTape over the fracture fragment if it's comminuted, and I'll pull that down through the tibia and then put it over another button down distally. That's my current technique talking about MCL, which we just had a nice talk about. I think you really have to divide MCL between superficial and deep MCL injuries and then the whole medial side of the knee. And I'm going to show you a nice case here where the entire medial side of the knee was gone. And each of the individual components of the medial side of the knee were easily dissected. Out here you can see we have a proximal tear. But this patient was much this this is actually just a standard MCL. And you can see right here where the. We're off at the femur. These are pretty straightforward. You can see this is a medial approach. You can see that MCL sticking up at you. We're going to put some stitches in it and use the SwiveLock there to anchor it down. And then run our internal brace distally. I can you can do a percutaneous approach here because it's not a tremendously involved MCL and anchor it down distally. You can also do this for the LCL. And here's an LCL that's popped right off the fibula. We're going to make a lateral exposure. We're going to do a drill, our oblique tunnel entering Anterolaterally and out posterior immediately. And I like to run that that FiberTape through that tunnel, bring it up and anchor it at the epicondyle to reinforce things. I've also got another technique sometimes that the the top of the fibular head is a little comminuted. You don't have great bone. You can't get good fixation. So stick this one in your pocket. You can take you can do an No oblique drill through the fibula and exit down on the neck of the fibula there. And you can you can drop a button in there and get a far cortical bite. And that's a great technique to to allow you to pull down soft tissue to a little compromise. Proximal fibular bone. I forgot to include the picture with the buttons in there, but the button would be sitting on there just like you'd do. You'd use anywhere, and that's the fine. Finally, the FiberTape being brought up independently and tacked up at the epicondyle to reinforce the construct. You put it all together. Acl, PCL, MCL. And this is that case I was talking about. Have a have a look at this one. It's great anatomy on the medial side of the knee. Let's see if we can get it to play here. He's got grade three valgus wide open. The entire medial side of his knee is ripped open. And as is typical with these things, you can see this is an ACL, ACL, MCL, laxity. Okay. So you can look at the anatomy here in a single 4 or 5 full fed Corkscrew to bring up the whole posteromedial capsule. And now things look a lot more orderly. We still have this portion of our superficial MCL. We can also see over here we got the Mpfl that's going to come over the top here, and we've got a little bit of the meniscofemoral that we're going to tack underneath there, and it's all going to come together real nicely, as you can see, and close the whole medial side of the knee. Now we can go in and scope the knee and our fluid will actually stay in the knee. So sometimes you just got to get in there. This is these are the repaired cruciate ACL and PCL. This is five days post-op. Nice res. Just a little bit of lag to be expected with such a big surgery. Now go ahead and bend it for me as best you can. And you haven't been to any therapy yet, have you? No. Not yet. So we've already got 90 degrees range of motion. And we've got good active quad because we didn't beat him up too much with the surgery. See here. We've already got 90 degrees range of motion, and we haven't really done any therapy yet. Okay, he was off pain meds in three days. We can see here that we just have a slight jog to posterior draw, which is fine because most most posterior cruciate ligament reconstructions end up with a slight jog. And then anteriorly we've got no movement where we brace the ACL. We can see here nicely that the Lockman exam is completely negative. And if you come over to here, we're going to look at the valgus exam and show that it's not moving at all. The valgus that patients five days post-op from a triple ligament surgery and is not on any pain medicine whatsoever. At some point we have to think about the injury that we're causing to the patient and how much pain meds and how much stiffness. And we have to find the right spot to where, where repair can fit into our algorithm. We can't just go in and reconstruct everybody. It is not necessary. We can use a preservation first approach, and we just have to refine our techniques and and we'll see the benefits of these procedures. So in my practice in my study group, we looked at the multiple ligament injured knee. And we looked back in a retrospective study from 2009 to 18. And we tried to figure out how many times we were able to repair the ligaments. So we had 48 patients, average age 32, 54% male. And we looked at the demographics, the injury patterns, treatment and short term outcomes. What we found was that 46% of the injuries were CD one, including one cruciate and one cruciate, and one of the collaterals, and then 54% of them were CD three, 40% were medial and 14% were laterals. And what we found was pretty interesting. 53% of the ACLs that were torn had proximal tears. So that's a little more common than in the isolated ACL tears for pcls of about 47% proximal but also 11% distal MCL is 55 were proximal, 39% distal and Lcl's 53% were distal. Most of them were distal. When we could get them, we found that we were able to repair 55% of all the ACLs that we encountered, 73% of the ACLs, 88% of the Mcls, and 87% of the Lcls. When we looked at multivariate analysis, we found that age over 35 was predictive of whether we could repair those ligaments. And again, so it's that older age group that tends to pull the ligaments off the bone. Personally, I believe it's a vascular issue, just like the rotator cuff tears right at the bone because of watershed areas. I think the same thing happens to the ACL. And then BMI, the lower BMIs tended to be a little more little more frequent. Incidents and repairability. So of the ACLs, 98% were torn. And when we looked at all the multi legs, they always had an ACL involved, 55% were repaired and only two out of 23 of those failed. Both of them were distal pcls 56% torn, 73% repaired, three out of 18 loosened up on US and MCL, 69% torn, 88% repaired. None of them loosened up, and LCL 31% torn, 87% repaired, and 18% loosened up. Of the 43 patient, 90% were eligible for repair of at least one ligament. Again, I'd like to thank my research team for helping to publish and analyze all of this data, and I do believe that a ligament preservation approach is appropriate in these severe injuries. Thanks for your attention.

Alternatives in Multiligament Treatment

Armando F. Vidal, MD (Vail, CO), explains his rationale for treating MCL injuries.

MCL Management: A Paradigm Shift?

My first talk is to talk a little bit about MySQL management and a paradigm shift. And I was reflecting a little bit on it. And you know, this talk is not going to be about internally bracing every MySQL you see or doing allograft reconstructions, but rather it's going to be about thinking of the MySQL in a different way. I think the orthopedic dogma for so long has been all mcls heal. You can ignore them, just treat the other cruciates or just leave them alone. And I think that, you know, we always talk about the lateral side of the knee being, you know, the dark side. But I would argue, I think the medial side is becoming the dark side. I think that we lack a lot of understanding about the anatomy. What are the critical structures. And we lack the understanding of reconstructive techniques that are successful. And we're just beginning to gain that understanding. We're pretty much where we were with the lateral side of the knee, maybe I'd say 5 or 10 years ago, where lapradd, etc. have really expanded our knowledge. So we're going to talk about I just want you if there's any take home point from this talk, is to think about the medial side of the knee differently than the way we're all taught in residency, which is they all heal and leave them all alone. So as we know, the MCL is the most common ligament injury in the knee. We see it in all of our collision athletes. We take care of a lot of skiing population and as you can imagine, I'd say every ACL we see is an ACL, MCL and the majority of these injuries can be treated non-operatively. Thankfully, the medial structures, the medial complex is very vascular, has great intrinsic healing capacity. But again, the paradigm shift, in my opinion, is to think of it as a more complex structure, not just a superficial MCL, which is what we're all trained to think about, but the posterior oblique ligament, and to think of it as a medial complex. Right? The deep MCL, the superficial MCL, the capsule, the medial meniscus and the posterior oblique ligament. Because they're clearly I think all of us in this room have seen MCL injuries that were like, there is no way that's going to heal. Or you examine that patient and they open up in full extension 30 degrees and you're thinking, I know I've been told to leave these things alone, but there's no way that MCL is going to heal on its own or this knee is so unstable. I need to do something about it. And because the orthopedic dogma for so long has been leave them alone again, we lack an understanding of what the best reconstructive or repair options are in that setting. So when you think of an MCL injury, I want you to think of it as a medial complex injury. And I have a talk later on the lateral side. That's where the lateral side is now. Right? We talk about the FCL, the Popliteus, the ligament, etc.. I think you need to think of the medial side the same way, because clearly some of these more severe injuries that involve the pol don't have the same intrinsic healing capacity, I would argue, as just a superficial MCL injury. And there's controversy about what to do in the multi ligament injury, specifically ACL, MCL. But clearly in a more complex injury like Doctor Hatch presented, there's no ambiguity about what to do for those injuries. So very briefly, I don't want to spend too much time discussing the anatomy, but the top part of this slide is critical. So there's a superficial MCL. We all are familiar with that structure. There's a deep MCL which is really the meniscal attachments in the capsular thickening. And then there's the posterior oblique ligament, which is that that oblique structure that comes across. And that has an important role in restraining valgus, but also has an important role in the In the rotational stability of that tibia. There are a variety of medial dynamic stabilizers. But these higher grade injuries, these injuries that open up ten millimeters or so, often involve injury to the superficial MCL as well as the posterior oblique ligament. So part of the challenge is that all the papers you see, and there are tons of papers in MCL management in isolation, there are tons of prospective randomized trials looking at ACL with MCL and treating the grade three MCL, Operatively or Non-operatively. But the challenge is that they all rely on this AMA grading, which is back from the 60s. And so the AMA grading, as we all know, it's, you know, five, 5 to 10 greater than ten is grade one, two and three. But the challenge is notoriously inaccurate. It relies on your subjective exam, but more importantly, has no correlation with treatment or outcome. Right. So Jack Huston in the 90s said, well, maybe we should add an endpoint to that, to that grading system. But it does beg the question whether or not that correlates with outcomes. So a lot of us at this point have looked at stress radiography. So Doctor Laprad really has popularized that for both the medial and lateral side. I use it pretty extensively, but it's hard to do it in acute injury and opening in full extension. So we're all taught that opening in full extension means that there's a cruciate and a collateral. But I would argue if you have a patient like this, this is a guy I saw on Tuesday. This is this is a severe injury. He actually is getting his MRI today. I haven't even seen the severity of his injury. But I can almost guarantee that this is going to be an operative MCL. And I'm sure he's got a cruciate ligament as well. And when they open up in full extension and you've got to be it's challenging because sometimes these acute knees you can't get into full extension. But if they open up in full extension that's a more severe injury typically is going to involve the superficial MCL, the deep MCL and the posterior oblique ligament. The controversy, again, is because a lot of these and we're part of this paper, part of the moon group. We looked at our outcomes of grade three MCL with ACLs didn't really show a significant difference in outcome if they were operatively repaired, but again, a lot of them are based on archaic grading systems. And just in the interest of time, I think if you abide by the rule that you know this, that all mcls can be treated non-operatively. What do you do when you encounter this injury? Right. So this is an injury. You can see the MCL. I don't know if I have a pointer here. But the MCL where the Arrow is, is pulled off the tibia. It's rolled up. It's intra-articular. This is clearly not an injury that's going to heal. So you need to be able to manage these injuries that are more severe. You know, you have to have techniques that work. So in my mind, if it's a combined injury with posterior oblique ligament involvement and posteromedial corner injury, and I'm going to define that either by stress radiography with greater than ten millimeters of opening compared to their contralateral side, or opening in full extension. That's somebody that at least I'm going to take a more critical approach to and consider operative intervention. If it's a tibial site lesion, especially if it's a stenner lesion. So, you know, you guys are all familiar with the center lesion in the thumb. But if it pulls off the tibia and it's sitting superficial to the peasants tendons, that's an injury that's not going to heal and is challenge. That's one that I'm going to consider intervention, especially if I'm there for an ACL where I'm going to have the anteromedial aspect of aspect of the knee exposed in one way or another, whether it's a BTB or even just for my Anteromedial or sorry for my tibial drilling. Obviously, if there's intra-articular, ligament entrapment, symptomatic chronic injuries, and debatable whether or not in high level athletes or in patients who are already constitutionally and valgus and have high grade injuries, whether or not they should be treated. But these are all areas of controversy. And again, it's I think the debates are what's what are the structures that need to be addressed. What's the best classification system that's going to predict management options and outcome. And then what are the do these high grade injuries with posterior oblique ligament involvement heal the same as the injuries that we've all been told? Heal well just like a isolated superficial MCL. So this is where the controversy lies. And this is where the paradigm is shifting, because there's increasing biomechanical and clinical data that these higher grade injuries probably do need to be addressed or should be considered for surgical intervention. These are all cases that I've done in the last two months. So again, our skiing population has a high incidence of medial sided injuries. So this is a 20 year old kid, high grade ACL, MCL opening in full extension. I don't have the entirety of his MRI here, but you can clearly see he's got a tibial sided lesion. This is a true center lesion. He's got opening in full extension. You can do an ACL in isolation in this group, and you'd get away with it probably 90% of the time. But this is a lesion that I would argue is not going to heal well and should be addressed when they have good tissue quality. And I can primarily repair them, as you've seen in several other talks in other conditions. I do repair them, and I like to support them with an internal brace. So in my hands this is a BTB ACL. I think you can make an argument about a quad or some other graft, but clearly an autogenous graft. I would not harvest a hamstring, as Rachel indicated in her talk earlier with a high grade MCL. And it's subtle, but you can see a little lucency at the base of my screw there where I have my SwiveLock, and I'll show you how I like to do these internal braces with repair. The reason I use an internal brace in this context is that there is clear biomechanical data, and you've seen it with other Conditions that they are structurally better than repair alone and approach more normal kinematics. And I think the morbidity of adding an internal brace if you're doing a repair is pretty low. And for anybody here that's done an MCL repair, you know, it's like an Achilles. Right. So that thing pulls off. It's not like it's clearly pulled off. You just sock it back down. It's shredded. The tissue is hard to get suture in. So I think augmenting it in this context with SutureTape augmentation makes sense with very low morbidity. This is from Lee from his video on the Arthrex website. I didn't have a video of my own, so I borrowed this and just abbreviated it. But this is how I do it. So the repair is wherever the zone of injury is. In this particular video, it's at the femoral side. I don't like to use swivel locks, actually for my internal braces with mcls on the femoral side, because there's a lot of structure there. And I've seen swivel locks that can irritate patients. I have I took one my slides out in the interest of time, but I have one that's backing out. It's, you know, on this side of the knee, you have the MCL, the mpfl, the adductor, they're all inserting in that area. And a prominent hard anchor could be symptomatic. So this is a is a knotless FiberTak. You essentially create a loop on itself and you can pass your FiberTape through that loop. Now, the benefit of this is that it's a low profile on the femoral side, but you can actually adjust the tension afterward. And I can show you how to do that if you guys want. So it's a knotless FiberTak on the femoral side. Pass deep to the sartorial fascia, deep to the tendons. And then the tibial fixation is exactly what you would expect, which is a SwiveLock I would say a couple pearls on this is I like to put a pin into the tibia and find an isometric point, because obviously this is a static structure and is not very forgiving. Once I identify the static, sorry, the isometric point with a pin and loop my FiberTape over it, I take the pin out and then put a SwiveLock in, and I like to use peak SwiveLock on the tibia because this bone is really, really hard and can be challenging with the biocomposites. So the benefit of this is you put that in, you've achieved your repair, and then you can go back and tension it a little bit more after you've finished your cruciates or whatever other work you're doing. So so again, the key is that you create this blind loop, pass your FiberTape through it, leave five millimeters, do your fixation on the tibia, and then you can go back and readjust your attention. And I'll show you in the lateral side how I use similar techniques to adjust my tension on the collaterals after the fact. This is another injury. So this is a this is a guy. Actually, I just saw him for a six week checkup on Tuesday before I flew out here. Acl, MCL, he hit a tree. And this is a pretty diffuse injury. So clearly all the way back there's injury. There's injury to the superficial MCL, the deep MCL, the posterior oblique ligament young guy as well. Lateral blow to the knee on a tree while skiing. You can see actually the intent of this shot was to look at I use a TightRope FiberTag TightRope when I do these so I can adjust the tension when I do a reconstruction. So you can see that on the femoral side. And what what's interesting about this fluoro shot is I was just checking to make sure my button was deployed on the lateral femoral condyle, but look how much that medial side gaps. And I haven't done anything other than just pass my graph on the femoral side so you can see the drive through on the on the arthroscopic pictures as well. So in my hands this is also a BTB as I like it in these multi ligament injuries because it's such a stiff graft and I get such solid fixation. But with a diffuse injury like that, repair can be challenging because there's not a lot of good tissue. So you had a tibial site of lesion. The mid substance of the lesion or of the MCL is compromised as well. His pol actually was fairly sturdy. So we did a reconstruction. I like to use established fluoroscopic landmarks for that. We used a FiberTag TightRope with an allograft, and I still like to fix it with a post in a spiked washer on the tibia, about six centimeters distal to the joint line. Mike Baraga is a friend of mine in Miami. Likes to dunk it into the tibia using another FiberTag TightRope. And I think that's very reasonable. And we were able to primarily repair the pol, which was a more straightforward injury. But again, thinking of the medial side as a complex, you need to you need to account for all the different aspects of the injury. And this is a fluoro shot after everything's been fixed. And you can see how that medial side is, is clamped down. So I think in summary, not all MCL injuries, especially in the setting of ACL, are benign. Most of them are. And I think the orthopedic dogma that MCL he'll still stands. In terms of the superficial MCL, but if you take anything home from this talk, you need to be more critical in your assessment, evaluation and treatment decisions for these higher grade injuries. Again defined as involvement of the entire medial complex, superficial deep MCL and posterior oblique ligament. And clinically, you want to be aware of opening and full extension to get your attention and have a low threshold to do stress radiography in your office if you need to. For acute lesions, I like to do primary repair. I think you've seen that as a recurrent theme today. Internalbrace is Biomechanically enhances that repair and protects it. And for diffuse, chronic or revision surgery, I still like to do reconstruction and I like to use the FiberTag TightRope. I'll show you my technique on the lateral side which mimics this, which allows for reproducible tensioning after the fact, which can be one of the bigger challenges with collateral ligament surgery. So thank you.

MCL Management: A Paradigm Shift?

Michael Gallizzi, MD, MS (Denver, CO), demonstrates the use of the Vortex™ threaded bone marrow recovery needle to aspirate marrow from the posterior superior iliac spine (PSIS), including surgical preparation and approach, proper aspiration technique, and needle insertion and removal. Dr. Gallizzi also shares pearls on how to safely target the PSIS for aspiration. The unique threaded tip and vent holes in the Vortex needle allow the surgeon to control the depth and direction of aspiration.

Vortex™ Threaded Bone Marrow Recovery Needle for Aspiration From the Posterior Superior Iliac Spine

Hello, I'm Doctor Michael Gorlitsky from Denver, Colorado, and today we will be covering the technique for bone marrow aspiration from the posterior superior iliac spine or Sis, using the Vortex threaded recovery needle from Arthrex. This is my typical setup for harvesting bone marrow for any fusion surgery where the patient is in the prone position prior to draping. You'll want to identify and mark the size. This is done by gently palpating the area with your fingers to find the general location. Once identified, mark the size so that it is visible and gives a clear indication when you are prepping the sterile field. Note the use of a C-arm is recommended to assist with proper targeting for this approach. The C-arm is then used to identify the entry point to the Sis. The C-arm is oriented according to the patient's positioning and anatomy in the obturator outlet view. Fluoro shots are taken in the obturator outlet view to identify the entry point to the Sis, also commonly referred to as the teardrop. This targeting point provides safe and easy access to the ileum for bone marrow aspiration. When draping, the Rs entry point will be included in your overall draping and prepping area. Make sure you place your initial towel low enough, ideally at the bottom of the coccyx, to ensure you have enough field available. If desired, staples can be used to secure the towels. An initial layer of I o band is placed over the towels to secure the prepared area. Making sure your Rs entry point is visible, the c-arm is brought back in and the entry point and trajectory through the teardrop is reverified. Once Reverification is complete, the c-arm is again removed to avoid injury to the cluneal nerves during harvesting of bone graft. We therefore recommend a linear incision approximately 2.5cm anterior to the Rs and perpendicular to the long axis of the posterior iliac crest. Subperiosteal dissection may be used over the pieces on each side of the axis of the incision. To help avoid injury to the superior and middle cranial nerves. Using a 15 blade. A small incision is made at the desired entry point for the needle. A Kelly or hemostat can be used to spread the soft tissue down to bone. The tip of the needle is then placed into the incision, and the c-arm is reintroduced to once again verify the proper location and trajectory of the needle over the tear drop in the obturator outlet view. After the location and trajectory has been confirmed, the needle is inserted into the bone through the teardrop. This can be done one of three ways. Using a mallet to gently tap the top of the needle handle by manually twisting the needle into the bone, or by using the needles. Power adapter connected to a battery powered drill. It is also acceptable to use any of these three methods in combination with each other. The inner stylet of the needle is removed and the vacuum lock syringe is attached to the Luer lock on the top of the needle, making sure to hold the hold the handle of the needle in your opposite hand to keep it from moving while the syringe is being attached. Stabilize the needle with one hand and pull back on the plunger of the vacu. Lock syringe with the other, twisting in a counterclockwise motion at the top to set the vacuum as the syringe begins aspirating bone marrow. We recommend changing the depth of the needle every two cc's of aspiration to maximize the concentration of osteoprogenitor cells collected. This is done by alternating between half turns of the needle and one and a half turns of the needle. The graduated markings on the syringe should be used to calculate the amount of bone marrow that has been aspirated. The unique design of the Arthrex Vortex needle allows for precise depth control by rotating the handle of the needle to control the position of the needle tip rotation of the needle changes both the depth as well as the position of the vent holes, to maximize the aspiration area within the bone. When the desired amount of bone marrow has been aspirated. Unscrew the Unscrew the syringe from the needle, making sure to hold the needle with your opposite hand to keep it from turning. After the syringe is removed, replace the stylet into the needle, making sure that it locks into place. Removal of the needle can be accomplished three ways. The first way is to unscrew by hand, turning the needle counterclockwise until it comes out of the bone. The second way is to pull the needle out by grasping the handle firmly with one hand, and moving in a back and forth motion until the needle pulls straight out. The final way to remove the needle is by powered removal using the needles. Power adapter connected to a battery powered drill, and running the drill in reverse. It is also acceptable to use any of the three methods in combination with each other after removal of the needle. Always check the tip to make sure that all the threads are present.

Vortex™ Threaded Bone Marrow Recovery Needle for Aspiration From the Posterior Superior Iliac Spine

Noman A. Siddiqui, DPM (Baltimore, MD), provides a step-by-step surgical demonstration of the Arthrex MIS Bunionectomy System with the triangulation guide, focusing on critical anatomic landmarks, fluoroscopic cues, and practical tips and tricks. The goal is to shorten the learning curve, improve OR efficiency, and deliver consistent correction, helping surgeons build confidence in adopting and performing minimally invasive bunion surgery.

Building Confidence in MIS Bunion Surgery: Practical Tips, Key Landmarks, and Fluoroscopy Views

Building Confidence in MIS Bunion Surgery: Practical Tips, Key Landmarks, and Fluoroscopy Views

FiberTak® SpeedBridge™ repair is the next evolution of knotless rotator cuff repair using self-punching 2.6 FiberTak RC soft anchors for the medial row and trusted Knotless SwiveLock® suture anchors for lateral fixation. The FiberTak RC anchors feature a fixed FiberTape® suture with swedged suture tails for simplified suture passing and the option of a tensionable knotless mechanism or sliding SutureTape.&nbsp;

FiberTak® SpeedBridge™ Repair

FiberTak® SpeedBridge™ Repair

At the Arthroplasty Evolutions course, Asheesh Bedi, MD (Ann Arbor, MI); Patrick J. Denard, MD (Medford, OR); Brian C. Werner, MD (Charlottesville, VA); Anthony A. Romeo, MD (Chicago, IL); and Evan S. Lederman, MD (Phoenix, AZ); provide literature-based consensus statements from the Shoulder Arthroplasty Research Committee (ShARC) regarding various surgical considerations in both anatomic and reverse total shoulder arthroplasty (TSA).

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Shaping Arthroplasty Outcomes With ShARC Consensus Statements

OrthoPedia: Shaping Arthroplasty Outcomes With ShARC Consensus Statements

Justin W. Griffin, MD (Virginia Beach, VA), presents a case and details a technique for suprapectoral biceps tenodesis using the Knotless FiberTak® Biceps anchor.

Case Presentation: Suprapectoral Biceps Tenodesis Using the Knotless FiberTak® Biceps Anchor

I'm Justin Griffin from Virginia. I'm excited to share with you a new development in my management of the biceps tendon for my patients, the Knotless FiberTak biceps. First, I'd like to share with you a case of a patient that I chose to manage the biceps in a particular way. This is a 68 year old active female with right shoulder pain. She had pain for several years, had failed conservative treatment. She was very active with different activities including gardening. She started to lose sleep and then she started to have problems with her functional activities due to pain on her exam. She had a difficulty with range of motion. She also had a positive O'Brien's with some biceps groove tenderness, a little bit of weakness in her rotator cuff and also some limitations with range of motion. Here's your MRI. You can see on the MRI that she has not only a rotator cuff problem, but also at her superior labral attachment. We can notice that she has a tear. She could, of course, have a superior label repair, but this would not be my choice for her. A debridement alone could be considered, but I don't think it would completely manage her pain. And then we could of course, consider a tenodesis, which is what we chose in this patient. The knotless FiberTak biceps offers a number of advantages. First, it creates a very small drill hole. Second, it's very simple and efficient, and it creates a strong repair through an interlinked double loaded knotless mechanism. So the way to perform this is first I pin the biceps through a spinal needle in an intra-articular manner. Then I release the biceps with arthroscopic scissors. You can also release the biceps with your Apollo, which creates perhaps less bleeding. And you can see that we can do this very efficiently here in the joint. Next I'll bring the shoulder into forward elevation. I'll really identify in the sub deltoid space where my portal should be. We create an inverted triangle between our anterior or lateral and our anterior inferior biceps portal. We'll create this and then place a passport cannula for efficient suture management. Once we have our passport in place, we can identify the biceps and really skeletonize it in the groove. We can see that we're working medially and laterally here. We have to pay careful attention to the little things. We don't want to get a great deal of bleeding, which makes the procedure more difficult. And we want to avoid violating the sub deltoid fascia. That's where the passport really I find helpful. Once we have our space managed quite well, we can then sweep the biceps more laterally, place our drill guide into the biceps groove, and we can feel the guide falling directly into that biceps groove. Then my assistant will efficiently place this anchor in a cortical manner. Once she enters through that one cortex, you can see that we place the anchor directly into the bone, and then we're ready to manage our sutures. The next step, as you can see, is we go ahead and grab the white suture directly around the biceps. This is going to serve as our loop. We can then take our passing device. Pass this directly through the biceps and retrieve it on the other side. We want to take a really good bite of the biceps. I try to enter directly through the central portion of the biceps, and then pull the suture up. And then we're ready to manage this. Sometimes I'll pull the loop down just a little bit to allow me to be able to see the loop better, to manage it on the other side of the biceps. Our next step is we're going to grab our other suture, which goes into the other Knotless Knotless mechanism. As we know, this is a double loaded knotless anchor. We can then retrieve our blue suture through the white loop. As you can see here. This is then loaded onto the passing suture. And we can then tension this down to obtain stout fixation in an interlinked way. I always like to look at my repairs. When I'm complete, I'll move my scope to anteriorly. As you can see here, we're going to move the scope anteriorly. And we'll be able to see that this is a very stout repair in an orderly fashion, and all we have left to do is remove the proximal unhealthy biceps. I typically will take a KingFisher and grab the biceps, elevate it up because it was moved in an anatomic fashion. And then subsequently I'll take that portion of the biceps out and we're completed with our biceps. Tenodesis Postoperatively I keep all of my patients in a sling for four weeks. We begin active range of motion at that point, but we're not starting any strengthening until six weeks. In this case, we've highlighted the fact that there is an easy and efficient way to manage the biceps in an interlinked knotless way. We've created an on lay biceps tenodesis and takes advantage of the optimal length tension relationship. This is also a knotless repair, which makes it efficient, smooth, and seamless in your operating room. Thank you for your attention.

Case Presentation: Suprapectoral Biceps Tenodesis Using the Knotless FiberTak® Biceps Anchor

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

Achilles Midsubstance SpeedBridge™ Surgical Technique

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

Achilles Midsubstance SpeedBridge™ Surgical Technique

John J. Christoforetti, MD (Dallas, TX), Benjamin G. Domb, MD (Chicago, IL), Ajay C. Lall, MD (Chicago, IL), and Michael K. Ryan, MD (Birmingham, AL), debate the roles for acetabular labral augmentation and reconstruction as hip joint preservation techniques in this panel discussion. Panelists discuss the role each technique plays in their practice and outline case-specific examples to support their respective use of these emerging techniques.

Panel Debate: Labral Reconstruction vs Repair With Augmentation

Panel Debate: Labral Reconstruction vs Repair With Augmentation

Patrick A. Smith, MD (Naples, FL), demonstrates an ACL primary repair using the ACL Repair TightRope® implant and FiberRing™ sutures.

ACL Primary Repair Using the ACL Repair TightRope® Implant and FiberRing™ Sutures

So this is a left knee. And this particular specimen has a proximal ACL tear. You can see here's the ACL. This is the Anteromedial bundle. You can see almost a split with the posterolateral bundle. Complete tear off the wall. You can see the back notch area. And I think this would be suitable to a primary repair. My goal would be to put two good sutures with the fiber ring, one more toward the anteromedial footprint and the other toward the PushLock bundle here. And I'll show you that my first step is to prepare the footprint to get good healing. And for that I utilize the Arthrex PowerPick. So we bring the PowerPick in through my Anteromedial portal. We deploy it. And then what I like to do is kind of figure out where my absolute anatomic center of the ACL is. And there's kind of the over the top position here. So my first hole that I make is going to be where I'm going to place my fixation position for the TightRope, which will also have the internal brace. So to me that looks like a really good spot. So I like to make my first hole right there, and I'll kind of make that just a little bit bigger. So I can just make sure I can pass my spade through there. So I make my first hole there. So again, that's going to be my center of the ACL attachment. Then I proceed to make several other holes in the footprint. And I'll clear that debris out with our shaver. So you can see I've got the footprint nicely prepared now with those holes. You know, you could come in with a caret and do some further debridement, but I don't mind if I leave a few native ACL fibers still on the wall here to enhance the healing process. I think the PowerPick is enough to get good preparation. So our first step now, as we get ready to do our primary ACL repairs to create our femoral hole, which is going to be the passageway for the adjustable loop device, which has the attached FiberTape for InternalBrace. So remember I passed that first PowerPick hole at what I thought was going to be the center for my attachment point, which I think is really good right there. So I hold the spade tip. I'm coming through the anteromedial portal, flex the knee. So we bring our pin in about 120 degrees of flexion. So we're at the right angle. And then we drill that pin. As I said I drilled the spade tip from the anteromedial portal knee flexion 120 degrees out that center point on the lateral wall where I wanted my attachment point for my ACL fibers with the adjustable loop device and where the internal braces will be located. So now we simply pass a shuttle FiberLink through the notch of our pin. We'll pull the pin out and laterally here. So you can see now looking for the Anteromedial portal. That's my center point for the anatomic attachment of the ACL back to the femoral wall. I'm just going to come in through my lateral portal and just going to shuttle this out the lateral portal. And we just take a hemostat and we'll just stat that. So of course that'll come back through the amp portal with the passport later when we pass our TightRope. So there's our shuttle suture in the femur. I think optimal position to attach our primary fibers. And you can see externally here we've just passed it out the anterolateral portal. So now I'll go to the tibia to create my passageway for my shuttle, for my internal brace in the tibia, through the intact tibial stump. So to do so I utilize the tibial aiming device from our ACL set. And I like to position this within the anteromedial base of the ACL somewhere about right there. So make an incision on the tibia. I'll make this just a bit longer because it's a demonstration here. It's usually about a centimeter. And this is going to go down to the tibia. We'll clear off that periosteum. And this is where we'll fix our ultimately our SwiveLock for our internal brace. I utilize A24 small pin here to come out again primarily within the Anteromedial footprint somewhere about right there. So we bring our guide sleeve down to the tibia. So this is a two for cannulated pin. So through our small incision here's our guide sleeve two for Cannulated pin. And we'll watch it come in arthroscopically. Right in the middle of the guide. Perfect position. So at this point we will take our aiming device off. And then again this is cannulated. One little trick. If there's bone in the end of the pin, if you just rotate it in, it pushes the bone out by rotating the cannulated pin there within the larger pin. So now we take out that smaller pin and we have our cannulation opened up and we shuttle through a wire. And this will be our shuttle for the internal rotation of the tibia. We have the FiberLink on the femoral side and the wire on the tibia. So we thread the wire. I take my looped grasper There's our wire. So I'm just going to hold the end of the wire that I brought through the Anteromedial portal. And then we'll just back out the larger pin, which is again a small pin at 2.4. So now I have my shuttle from my joint side to the tibia for the internal base later on. And like I did with my shuttle switch in the femur, I like to now pass the wire out the anterolateral portal. So it's out of my way with my passport, and we'll just bring it back through later. So just a little simple step to keep it out of the way. So I bring this now out and we'll snap that. So now we've created our pathway for our FiberTape later on for the tibia as our internal brace. So the next step is we've got to place our ACL sutures with the fiber ring. And we definitely need a passport cannula so we don't get any soft tissue bridges. I like the eight millimeter size passport. This is a little bit larger than these. This is 40mm long. You could use a 30 and a smaller knee. So through the anteromedial portal we just insert our passport simply like that with our inserter. And now we're in. So there's our passport, and we'll put a ring on this one here just to give us good support on the skin. So now we're in shape to pass our sutures. So a very critical step is proper loading of the FiberRing. Here's a 25 millimeter fiber ring. This is going to be for my cinch suture through the ACL fibers. And the way you do this is you pass the fiber ring over the top of your fast pass Scorpion first in the next step is to take the free end and lock it into our fast pass. Scorpion. So now we're ready to go. We've got our fiber ring pass over the shaft of our Scorpion fast pass. We've loaded the free end so we can create our cinch. Our goal is to get a good bite in those proximal torn fibers. Generally, I'm about the mid substance of the ACL utilizing the 25 millimeter ring. If you had a situation where you needed a more distal bite toward the tibial stump, then I would go with a 35 millimeter long ring. But we're going to use a 25 millimeter, which is what I generally use for both of my suture passes. So I'm going to come through my passport cannula And again I like to pass one on each side basically. So I'm going to bring my Scorpion. Here's about the mid portion. You know here's the upper part of that tear. So I want to make sure I can advance fibers to the wall. So I'm going to come in here get a good bite within my Anteromedial bundle footprint right there. Capture it and bring that out and create our first synch so you can see how that was done. Now I'll just pull that free end now to synch it. I'll make sure I'm happy with that bite which looks really good. So that's my first pass. Now we're going to make our second pass loaded the same way. But this time I'll come from the other side. Now I'm going to make sure I grab some of the post lateral bundle. So I come underneath on this side now. Make my second pass. Captured in the jaws. Slide the FiberRing down and create my synch. So you can see. Now I've got two good cinches within that proximal ACL tissue. So I'm very happy with that. So here's the critical explanation for the technique of the adjustable loop device and how it works. You can see that distal to the cinches is this open loop. And that's the FiberRing. Again this was 25. If you had a 35 it would be longer. But this suture right here allows us to shuttle to create our TightRope, which we'll do outside the joint. So again the key here is the TightRope is not pulling on the sutures. It's pulling on the loop distal to the cinches. And that's how we pull our fibers up to the femoral wall to get a good secure primary repair and get tissue to the wall. So that's the key thing. And to do so we have the shuttle ring. So at this point they're wedged together. We're going to go ahead and cut the first one Just for ease of suture management, we can pass one of the FiberLink stitches out the anterolateral portal just to get it out of the way temporarily. So I'm going to do that here. The initial FiberRing is wedged together. We don't need that swedge any longer, so we're just going to cut that. And what I want to demonstrate I want to show you arthroscopically as well. You need to make sure that you have a free passage. You can see how it slides. So you want to make sure that the free end of the suture slides freely through that distal loop of the FiberRing. Because what's going to happen is this loop is going to transfer step one of our TightRope that we're going to make outside the passport through that ring. We'll pass the first one, and then I'll bring back the second one and pass it the TightRope through that one as well. But this is the mechanism. Just as a step, just always check and make sure that slides freely, which it does. So now here's our TightRope card outside the joint to create our BTB TightRope essentially. So we pass step one through the ring. And you'll see us pass that arthroscopically you can see it come through. So here's step one. That's through our first ring. Now we need to pass it through our second ring. So now I'm going to retrieve my previously passed second suture, which I just parked in the anterolateral portal. I'll bring that back out. The passport. Now, once again, we cut this wedge. We'll slide that suture, and you'll see it slides freely through the ring. So now we just do the same thing with step one, which is the black and white here. We're just going to shuttle that through the second ring. And you'll see that come through. So step one is bringing the loop of the BTB TightRope through both of the outer rings as you see there. So there's our loop. And we just did that with a passing shuttle suture that we cut off. Then we take step two from the card. We're going to pass that through the loop. So we pass step two. So now we're just going to pass an inch or two. And this makes it easier to pass and complete the TightRope mechanism. There. So that's actually our other shortening strand. And then we've got to take everything off the card. That's easily done by flipping the tabs here. You can see the blue FiberTape. Our InternalBrace is already attached to the button, which we'll show you in just a second. Here's our TightRope that we've created. And the first thing is, we wanted to make sure our shortening strands were equal length. You want to make sure you have enough length from the tip of your button, which we have plenty. So it passes out the lateral femur to flip the button. You don't want this to be too short. So notice the FiberTape is passed independently through the button already attached for you. And this is our passing suture for the button. So the FiberTape is going to stay here because that's going to ultimately be transferred into the tibia via our wire that I passed earlier. So my next step is I've got to retrieve my femoral shuttle suture, which remember I parked out my anterolateral portal. So we're going to get that loop. So I just bring my loop grasper through my Am portal. And I'm going to retrieve that shuttle suture right there. So now that loop we're going to pass the two blue passing sutures on the button and the two shortening strands for the adjustable loop. Tightrope, which is how we're going to pull those proximal sutures and the ACL fibers up to the wall. So we're just going to pass that. You can watch that come out. So we've passed with our femoral shuttle. We brought out our small little anterolateral skin incision. These are our two short strands of the adjustable TightRope. And these are how we're going to pull the fibers of the ACL up to the femur that we talked about earlier and allow for tensioning. So at this point I'd like to get a bit of slack out of the system because I want to pass my internal brace first and fix that before I do my final tensioning. So we're going to go ahead and take a little slack out of the system, which is going to going to be here with our button. We pass our button right there, get it to flip on the outside of the femur. So one way we can confirm that we're flipped with the independent InternalBrace on the TightRope. If we pull on the FiberTape hard, that button is going to sit on the femur. It also is very helpful for your post-operative x ray, because by pulling hard on these two fiber tapes, there will be no gap of soft tissue. You're pulling that button right to the lateral femur. You can see me pull hard on that femur. It's definitely flipped. So you don't need x ray because you've confirmed it with that manual pull. So what I like to do at this point is get a little bit of slack out of the system. So now watch as we pull the shortening strands. You'll see. We'll start to pull those ACL fibers up toward the femur a little movement of our white shortening strands. There you go a little bit more just about right there. You can see what we're doing. That's good. We'll stop there. That's the pull. And again this is really nicely seen on the video. The pull of the fibers is through the ring, not directly on the cinches. We just have reduced the slack in our shortening strands. But again, I want to first fixate the internal brace. So what I do now is I'm going to pass my wire that I passed earlier. So I come through my passport cannula, I grab my wire, which I parked out that anterolateral portal right here. Pull that back. So now I'm going to take the wire, and we'll pass the two ends of the internal brace through the wire. So now we're just shuttling the internal brace. You can see where it is in the tibia right there with the wire. So now I bring the internal brace out here. So there's my internal brace. And you 100% need to have an internal brace to do a primary pair because of the biomechanic stability it provides for the repair, sutures alone are not going to be enough. So there's my IB. It's kind of where I like to be. I like to be along the Anteromedial footprint there. So we're going to fix the internal brace first. So we're just doing our initial hole 4 or 5 or 5 hole for our SwiveLock. Anchor for our internal brace. You have to tap this bone. It is hard. So our next step is we're going to load the two ends of the internal brace through the eyelet of the 4.75mm diameter biocomposite SwiveLock anchor. So we take our slack out of the tapes. We bring the knee into full extension. And now we're going to remove the tap and put our anchor in place. So now we screw our swivel lock down hold the paddle again I do this in full extension. So now we back our swivel lock out. So now we'll just cut our fiber tapes here on the tibia. Here's our final step. Our internal brace is in place. And now we'll finish our tightening of our sutures up to the wall with our shortening strands. You can see the tissue gets pulled up very up very nicely as the slack comes out of the shortening strands, and I can fix this in any degree of flexion, which is critical. When I started, those blue cinch sutures were right here and now those blue sutures are way up there. You can see we've got a great repair here. Tissue to the wall. But what I like to do at this point is I cycle the knee so I can eliminate any creep in the system. And again, I can fix this in any angle and I'm tensioning it. And this is the advantage with the adjustable loop device we can retention. So at this point we cycle the knee I usually do it about 20 times. And we'll retension our shortening strands up on the femoral side to eliminate any final creep in the construct. You can see a little bit more we got there. So now when we probe it for you. So here's now our final product. And this ACL is super tight. You can see where I started I had a complete Sherman two tear to start with. You can see I've got tissue to the wall. I've done my PowerPick right through there. I'm going to get some stem cell egress around it. Again, look how far those sutures advanced. Those sutures when we started, were right here. So we've advanced about a centimeter of tissue up to the wall. It's anatomically attached. Don't have to ever think about a notch. Plasty. Totally anatomic, no graft. And the eib's in good position. Good tension on the IB, which is going to protect the repair. Full range of motion. Full extension. Flexion. I'll cycle again and again a couple of times over and over just to make sure nothing moves. Nothing shifts. I start range of motion right away. I like using a CPM machine actually. Early weight bearing. Once they can do a straight leg raise or off their crutches. So it's a really quick recovery. So that is the advantage of the Knotless adjustable loop device, allowing for retention with the new FiberRing system making it easier. And you have your internal brace which you absolutely need to protect the repair going forward.

ACL Primary Repair Using the ACL Repair TightRope® Implant and FiberRing™ Sutures

This animation outlines the steps for safely entering the hip joint using the FlushFit cannula system and SafeCut™ capsulotomy blade.

Accessing the Hip Joint Using the FlushFit Cannula System and SafeCut™ Capsulotomy Blade

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

Accessing the Hip Joint Using the FlushFit Cannula System and SafeCut™ Capsulotomy Blade

Anand Vora, MD (Chicago, IL), presents a detailed overview of clinical evidence supporting evolving treatment techniques for insertional Achilles tendinopathy.

Insertional Achilles Tendinopathies: Literature Review on Evolving Insertional Achilles Treatment

OrthoPedia: Insertional Achilles Tendinopathies: Literature Review on Evolving Insertional Achilles Treatment

Matthew J. Matava, MD (St. Louis, MO), performs a clinical demonstration of a BTB ACL reconstruction using BioComposite FastThread™ interference screws combined with FiberTape® suture for the InternalBrace™ technique.
The InternalBrace surgical technique is intended only to augment the primary repair/reconstruction by expanding the area of tissue approximation during the healing period and is not intended as a replacement for the native ligament. The InternalBrace technique is for use during soft tissue-to-bone fixation procedures and is not cleared for bone-to-bone fixation.

Matthew J. Matava, MD (St. Louis, MO), performs a clinical demonstration of a BTB ACL reconstruction using BioComposite FastThread™ interference screws combined with FiberTape® suture for the InternalBrace™ technique.
The InternalBrace surgical technique is intended only to augment the primary repair/reconstruction by expanding the area of tissue approximation during the healing period and is not intended as a replacement for the native ligament. The InternalBrace technique is for use during soft tissue-to-bone fixation procedures and is not cleared for bone-to-bone fixation.

BTB Reconstruction Using FastThread™ Screws and the InternalBrace™ Technique

So here you are preparing the notch for an ACL reconstruction. We've already harvested the patellar tendon graft, and if you notice, there is no leakage of fluid coming out of our harvest site. Okay, so we're ready to drill our tibial tunnel. The question becomes how do you know how to set your tibial guide? In general, I like to set the guide such that it's at 55 degrees. Okay, that seems to work for most patients. Now, a key to this operation to me, when you're using two Bone-tendon-bone Autograft two bone plugs is you have to set your tibial guide length. Otherwise you're at risk for having your tibial bone plug sticking out of the femur. Okay, that's a problem. You can't use interference fixation. So how do you know how to do this? You can't just slide this up to the tibia because your wrist shorten the tunnel relative to the length of the graft, and then it'll be sticking out. This is especially important if you use an allograft, or if you have a patient who's five foot five and your allograft tendon is coming from a person who's six foot six, it's going to be way too long, so I have a formula I can use for that. So we'll do is we'll take the graft in total. Here's the length of the graft. So this graph measures about 85mm from tip to tip. The femoral bone plug measures 25mm. So I take 85 of the total length of the graph -25. That's 60mm which is what the intra-articular portion of the graph should be. And the tibial portion of the graph that's 60mm. About 25mm of that is going to be for the intra-articular portion of the graph. So I'll subtract 25mm from that 60mm. That leaves 35mm at a minimum that I need for the tibial tunnel. I had to cheat a little bit. I'll add to 40mm that way. I have no concerns that the tibial bone plug will be sticking out of the tibial tunnel. So I'll take our guide. We've already set to the 55 degree angle, and we'll set the tibial side to 40mm right there. That means our tibial length is 40mm. And by doing that you should have a bone graph that does not stick out of the tibia. That's customized for every individual patient. So we're drilling our tibial tunnel. We have our guide set such that the pin comes out just medial to midline, in line with the posterior aspect of the anterior horn of the lateral meniscus. So here's our pin. There's our anterior horn of the lateral meniscus. The posterior aspect of it. If you're concerned about the amount of impingement you have, you can take your knee in full extension under the scope and make sure there's no impingement of the notch. So that looks relatively acceptable. Typically this is going to be about 7 to 10mm from the PCL. Then we'll Overeem with a ten millimeter reamer. It's important to use a drill guide for this in a real patient so that you don't cut the skin. We'll take a Ranger to open up the aperture of our tibial tunnel to get all this soft tissue out of the way, because sometimes that prohibits the graft from being pulled into the joint. All right, so there's our tibial tunnel. And again, if you're concerned when you're first starting to do this, whether or not you have impingement, you can put can put your shaver up the tibia and extend the knee. And show there's no impingement. There's full extension. There's no impingement of our graft. So here's our trans our Am portal drill guide on the femoral, if you notice, has a little curve to it that allows it to go around the back of the intercondylar notch via the Am portal. So we'll hyper flex the knee to at least 105 degrees, preferably more. If you don't hyper flex the knee, then what happens is you risk blowing out the back wall when you drill your tunnel. So here's my finger guide is up against the back of the notch. I'm trying to go through the center of the Am portal for a single bundle reconstruction, and we're using a four millimeter spade tip guide wire because we're going to be using the TightRope device with the internal brace. Once you're through that tibial tibial cortex, we'll take our guide out and we'll pull this back. This acts as a depth gauge. You see there's markings on it. Usually most males are between 32 to. To 38mm in length. And here my spade tip is up against the far cortex. And that's about 36 maybe 37mm. You see there's the four on it right there. Okay. So that shows us how wide our femoral condyle is. Now we will drill this out through the skin. Great. Now we will take our low profile femoral reamer. It's very important that you clean out all the fat pad before you do this. If you notice, we've already done a good job of cleaning the fat pad. But I still want to make sure that there is no chance that I'm going to hit the medial femoral condyle with my femoral reamer. And that's the reason why Arthrex has devised this low profile reamer, because it works really well in avoiding that estrogenic complication. So that's pretty well cleaned out. You can use an 11 blade as well, but for the purposes of today did a good job with the shaver. Here's our reamer. There's a black line right here. And that black line is parallel in line with the blade. So you So you know, when this blade is inside the skin, you can't see any longer. You know the orientation because you can follow the orientation of the black line. Okay. You should always see the black line because you know that this is vertical. If this is vertical, it's not going to hit the femoral condyle. So we'll put the blade in. And as you're watching it arthroscopically sometimes if you lift your hand up a little bit, that helps it go in a little bit easier. Pass the fat. There you go. There it is. Nice and vertical. We completely missed our femoral condyle, which is way over there. Okay. But again we can still see our black line is vertical over here. So we've done a good job of avoiding that. So we have our low profile reamer in the joint. We've already prepared our notch. Now when we start to ream, I like to start the reamer off the bone, because I don't like to have the reamer on the bone, because I don't want to have any sort of risk of damage in the blade. We'll start the reaming and then we'll hit the bone. Now our femoral bone plug measures 25mm. I like to drill it two millimeters deeper than the depth of the bone plug. Here's our tunnel. Our back wall is intact. Looks good. We'll take the wire out. We have a FiberWire suture that we're shuttling through. We'll pull this to the tunnel until the loop is seen. Then we'll go through our tibial tunnel, grab our suture and pull it through. And that will be our passing suture. So here is our internal brace. Here's the button that will be deployed on the lateral femoral cortex. And if you remember, we measured our interosseous length of the lateral femoral condyle as being 37mm. We've made a mark from the tip of that TightRope anchor to 37mm. That's the way we know when the metal button is fully gone through the femoral condyle. Here's our passage. Suture. Now we're going to be passing up our internal brace suture as well as our Graf suture. So the internal brace is the TigerWire and the ACL graft is the blue suture. So Now in sequence, we're going to pass our TigerWire up that has the TightRope on it. And now a little Perl here will stop, and we'll put the scope in the Am portal so we can see exactly when that button goes out of the bone, and we can see where our mark is. Now typically I will do this under Fluoroscopic visualization. So I know exactly when my TightRope device has deployed on the lateral femoral cortex. Here's our mark. So we know we're very close. And sometimes you can feel a little pop once it goes through the femoral bone. Okay. It looks like he's probably through there. So our TightRope has been deployed. It's secure. We're pulling traction distally on that TightRope. It's very solid, as you can see. Once I get a pull, they're nice and solid there. So we feel good about that. We pass our BTB graft anterior to the internal brace, use a probe to help pull and change the direction of force of the as we pull the BTB up. So here it is in the femoral tunnel. Again, we made the graft big enough so that it should go very well. Now it's very key here when you're putting your BTB bone plug in the femur that your cancellous surface is facing anterior. Here's our mark we made earlier so we know how far to pull it up. But we're going to guide it in with this probe and pull it up. And we have to make sure that it's going in the tibial side as well. And there it goes. And it dunked in very nicely. All right. So we're going to use a Notcher. We'll put the Notcher. You want to drop your hands as much as you can so that you're hitting the bone of the tunnel. Great. Now we'll take our nitinol wire and our tap so we have a protective sheath over our tap, and we want to tap our tunnel to accommodate the screw. Again, the protective sheath protects the graft. It also protects the PCL, so there's no genetic damage from the tap. Now we want to grab tension on our sutures here. Approximately. We'll put our sheath up against the graft. Here's our bow composite FastThread screw. A nice squeak means our fixation is good. We're now line to line, and we'll take our insert off. Now, for a ten millimeter size tunnel and a ten millimeter bone plug, I like to go down two sizes on our interference screw. That's an eight. There's some research that shows you can go down to even a seven or perhaps a six. I get the best fixation, I feel, with the most ease of insertion. If I go two sizes down, if I'm using an allograft, I'll only go one size down on our screw. But there's our bone plug. There's our mark. We put make sure we're fully deployed into the tunnel. There's our screw, nice and flush with the bone. One final test. Make sure our fixation is good. We'll take the distal end of the graft. We'll pull, and then we'll cycle the knee from 0 to 9 degrees multiple times. Fully tension the graft. Make sure there's there's no impingement. We also want to make sure that there's good isometrics. So what I have is I have my fingertip on the aperture of the tunnel as he's cycling. If there's non-isometric placement on the graph, we'll feel these sutures go up or down the tunnel, respectively. You can have about two millimeters of play of the sutures going up and down the tunnel. In this particular situation, there was good tension throughout, but I always want to do that after you put your femoral screw in. So now we'll put our distal fixation in of our internal brace. We're gonna go just distal to our tibial tunnel. I want to clear the soft tissues off just for ease of insertion of the SwiveLock. So here is our tibial tunnel above. And if you notice, our tibial bone plug is not sticking out of the tibia. Okay. So we did our calculations earlier and we have good placement of the tunnel and good placement of bone plug without it coming out of the tunnel. So we'll take our spade tip pin go just distal to our tibial tunnel. This has a positive stop. We'll then tap it. So we've separated our BTB sutures and wire from our internal brace sutures. We've threaded the sutures through our SwiveLock. We're going to take our tap out. We're going to take the knee in full extension with our anchor ready to be deployed. And there's our anchor fully deployed. Now the question comes in how much tension should you apply? Really you can only apply so much tension to this suture as you're inserting your your anchor. By placing the in full extension, we're not going to entrap the knee or prevent full extension. We're starting out in a fully extended position when we put our internal brace in. Here's our BTB graft. Here's our nitinol wire. It's anterior because remember that's where our cancellous bone is. Okay. But you always have to make sure that your wire is in the tunnel and confirmed by viewing arthroscopically. It is not anterior to the tibia as can be done if you're not careful in this regard. So we'll take our interference screw and tap. Now, as I said on the femoral side, I'll use a screw two sizes down in the tunnel or the bone plug size on the tibial side. I'll go down one size because again the bone is a little bit softer. So in this situation we're going to use a screw that's one size smaller. Now we'll put the knee in full extension. Again we have two distal sutures and one wire. That way we know we're not going to lose fixation. Okay. Go ahead. If you notice, our bone plug is not sticking out of the tibia because we measured our tibial drill guide to ensure that doesn't happen. We have very good purchase on our screw. Here's our final grab construct. Looks nice and taut. Take the knee and full extension remains nice and taut. There's absolutely zero impingement of the notch. And again, keep in mind the graft and the internal brace were fixed independently of one another. The internal brace, which you can see behind the graft, acts as a seatbelt of sorts to protect the graft through extremes of force. As a backup. But our graft, again is doing the primary restraint as our final product.

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