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

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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

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?

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.

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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.

BTB Reconstruction Using FastThread™ Screws and the InternalBrace™ Technique

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

Thomas M. DeBerardino, MD (San Antonio, TX), demonstrates an arthroscopic, double-bundle, all-soft-tissue PCL reconstruction technique. Dr. DeBerardino prepares the femoral double-bundle side of the graft with FiberTag® TightRope® implants and the tibial end of the graft with another FiberTag TightRope implant. The FlipCutter® III drill and RetroConstruction™ PCL guides are used to create femoral and tibial sockets.

Double-Bundle PCLR Using All-Soft-Tissue Achilles Graft Prepared With FiberTag® TightRope® Implants

Today we're going to do an all inside Achilles allograft double bundle ACL reconstruction. The twist is we're going to use a all soft tissue graft without a bone plug. That means we will use a FiberTag TightRope ABS for the common tibial fixation point. The large end of the Achilles graft to which a bone plug would have been on, and separate FiberTag TightRope pts for both the anterolateral and the posterior medial bundles for cortical suspensory titratable tightening fixation. So here we have an Achilles. We've got the common bony side without the bone, and we've already placed our FiberTag TightRope on it. We've lengthened it the construct so it can go through the tibia and still come out the anterior cortex and be able to work with the working end. So we put a FiberLink cinched to the saddle of the TightRope abs. Again on the femoral side we have the Al bundle and the PM bundle the al. If you split your Achilles and take the turn into account, you end up with one bundle that's about a millimeter bigger than the other. Typically it's nine and an eight. In this case, we actually have a seven and a 6.5. So the Al will be the seven millimeter diameter and the 6.5 the PM. The beauty is this is good utilization of graphs. It's one graph with all of this collagen adequate or more than adequate one would say to appropriately overengineer the PCL construct. The total length of the construct is anywhere from about 80 to 90mm. This is a smaller graph for a smaller knee, so we've gone down to 80. You count for about 20 to 25 in the tibia and 15 to 20 here we have 17. So right in the middle 15 to 20mm of graft into your retro sockets using the FlipCutter three in the femur. This is our right knee. Arthroscopic view 30 degree Arthroscope lateral portal. Typical setup. Here we see our pseudo lax ACL. But we know it's okay because of our injury pattern. And we know that this ACL, when we enter draw back to its normal station, it's normal. So if we switch simply our 30 degree scope to the medial portal, here's our looped FiberStick passing suture coming out the front. So now we'll switch back to the lateral portal. And our job now is to drill our second femoral socket. We're going to do a double bundle because we want to put maximal collagen to maximally fill the footprint. A bundle goes at the top. There you have a seven millimeter retro socket with a cortical mantle and a TigerStick passing suture. Now we use the femoral PCL guide to drill the PM bundle. We are going to be what we say externally divergent. They're a millimeter off or two arthroscopically viewed. But we know externally from the outside view you can see we're externally divergent. So these are not parallel sockets. They're divergent. And less likelihood of convergence or breaking into each other. So we'll make a second stab incision. In bigger people, you can get away with one stab incision. Ironically, the smaller the knee, the more likelihood of two stabs, because you just don't have the girth of the knee to travel that incision from A to B socket. So here we're doing our second stab incision. So the only thing we want to check here. And on a thin knee it's easy. Want to make sure you're well behind the flare of the condyle so we don't break out. We're actually going to change this angle. And this is what you get to do with this system. So that we're drilling back. Pull that back just a little bit. That gives us a little more real estate on the condyle, less chance of breakout or even as people worry about. So we want it down in the corner. It's slightly on a 90 degree view proximal to the Al socket. This would be coincident with it. That's more proximal. It's posterior like we said. And that's the perfect spot. And there's still some barrier down here because this is the bare area we often trough out when we're doing notch based work for like, a meniscal transplant. So that's a good anatomic position. We'll drill almost to the cortex and take this out and watch the final breach of the inner cortex of the notch without the guide in. You're there. You're committed. Now, once you're that far. And so we'll take it apart so we can watch it really come through. That's the nice thing about this guide. And then we'll breach the cortex here. Nice. Keep it into the laser line. We want these graphs form fitted. But because we can't drill a 6.5 exactly with this FlipCutter design, we will drill up, not down, and try and get A65. And do a six might be too dicey. So we will drill up to a seven and that should be fine because this is good cancellous bone. And we're counting on the cortex for suspensory fixation, not the cancellous bone. So now we have our two passing sutures in the femur, and they're marked blue and white for a good reason. We want to make sure we keep track of track of them. We don't want to crisscross these graphs. So we'll keep these up here and just hang on to them. We are literally ready to bring the graph in. So we made an auxiliary portal on this knee. So we're going to decide to enlarge that portal because we have to get a large PCL graft in here. So you don't enlarge it until this point. So you lose less water and you can just do it toward the side away from your sutures. And it's a big enough graph that if you can get a glove, small finger in there, you know you're good. It's the same thing we do with the meniscal transplant. You want to be able to easily get your gloved finger in there, and that way the graft will pass expeditiously. So we'll use the tibial socket first and fill our tibial tunnel with the tibial end of the graft with our length suture. And it pulls the whole construct through. We can watch it Arthroscopically. Now we'll see the transition to the TightRope abs part of the FiberTag construct. We'll will keep tension on these so they don't get wrapped up, so we'll pull that in. All right. So now we've pulled in our tibial side of the graph. The reason you have to watch this here is you want to make sure none of your femoral sutures are tied up around your graft. And they are not. That's graft and no suture. If you see no sutures around it here, you're in the clear. We see all tendon, and we can climb up over and look down and see our blue mark. That's the second mark, because you're not going to see the first one, or you're going to run into two before one. So we'll over countersink it. And we know now the bone's right down there where that strand is. So I've now sunk a lot into the tibia. And so now just like with the femur on the ACL side, you can look right up this socket very easily from our lateral portal. And it's seven millimeters more. So he's just going to rock his wrist and it's out. So now he's going to circum duct it with the blue. And I'm going to pull back gently. So he's going to walk it in with the whites while we're looking at it. And if he walks it in 3 or 4 throws left right, left on the pull sutures, we know it's going to going to hold and I'm giving back tension pretty much hard tension. So that's pretty good. All right. Good there. Stop there. So that's the al in. It's a gentleman's pass. It's not tight. It's just in. That's what we want. We want to just park it. Same thing for the blue passing suture for the PM bundle. Our second FiberTag TightRope PT for the PM bundle is getting passed. Now the transition happens right there. Arthroscopically I'm holding back tension on the loop, the button still out the portal. We'll walk it in and follow it up with our arthroscopic view. Pulling with the blue sutures, trying not to get the button necessarily to come out of the skin. Seven more millimeters. The cortical man. It's out good circum duct and it's on. I can feel it peg against the bone. That's a good hard stop. So now we'll walk it in. All right. So that's there. So now we're going to pull on our tibia. We're going to really viciously cycle the knee. So let's do final tightening on the tibia right now. So now. So now we're happy. Let's hold off on the PM. So this counter sinks into the hole. It's got a little nubbin on it. So once we get a dimple in the skin we release the clamp. We do a little finger sweep with a mosquito to make sure the soft tissue is allowed to go to bone, and the 3.5 pilot hole will be occluded by the nubbin on this special ABS type button. So I toggle it in inflection. We've got good resting tension. We already checked our al. It's the main holder of the femoral side, so we're good. We're not going to suck it back out of our femur. So we know we've kind of set the limit. But this gives us a fixed point that we can. Finally, as we said at the outset, we can retention and tension again on the femoral side until our heart's content as the surgeon, which is what we'll do now. All right. So here we are. Al is reasonably tight, terminally fixed on the common tibial side. Now we're going to walk in our residual PM bundle tucked in nice. Looks pretty anatomic. We filled the footprint with a Big Al and a less big PM bundle. So now we do final tightening of the PM in extension. Good. All right. So now that's a posterior drawer. So we want to do an anterior drawer and do final al bundle tightening. And that's well balanced. A it's well balanced because we marked it ahead of time. B you can see the blue marks there. You can't really see the we've occluded it with good collagen. So we can't go through Hal's triangle very easily. You can if you have to. And here we are showing you what you can do if you have to. You can get back here and see if you've, you know, lost a loose body or some fragments, but you can see very easily. We've done this whole case with a 30 degree scope, so it is clearly doable. You can climb up over your graph through house triangle and get right back in and see your blue line right as it goes into bone right there. So all is good. Double bundle boneless Achilles allograft PCL reconstruction.

Double-Bundle PCLR Using All-Soft-Tissue Achilles Graft Prepared With FiberTag® TightRope® Implants

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

Peter C. Yeh, MD (Stoneham, MA), shares a surgical pearl for using a weighted clamp to optimize graft passage during all-inside ACL reconstruction.

SpeedPearl: All-Inside ACL Reconstruction Using a Weighted Clamp

All-inside ACL reconstructions require a level of precision and preparation, as proper graft and suture management are keys to ensuring a smooth case. Here's a simple but very effective way to pass the graft into the femoral socket. Rather than having an assistant's hand pulling on the tibial shuttle loops, I use two clamps to weigh down the tibial shuttle loop suture that comes out of the Am portal and tibial incision, taking advantage of gravity to tension it down and out of the way. The heavier the clamps, the better. This allows for ease of graft passage, but more importantly also frees up an assistant's hand to do something else to further the case. One clamps both sides of the tibial shuttle, stitch both the Am portal side as well as the tibial incision side. For extra weight, I put an additional clamp on just the suture loop coming into the Am portal to make it even heavier. This allows tension on the suture and allows for the passage of the graft without worry that the tibial shuttle sutures will get pulled in.

SpeedPearl: All-Inside ACL Reconstruction Using a Weighted Clamp

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

Revolutionizing Ankle Arthroscopy Using the NanoNeedle™ Scope 2.0

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

Revolutionizing Ankle Arthroscopy Using the NanoNeedle™ Scope 2.0

At the Orthopedic Technology and Innovation Forum (OTIF), John D. Adams, MD (Greenville, SC), reviews the latest literature highlighting trends in the surgical management of intertrochanteric fractures and the associated clinical outcomes.

Intertrochanteric Fractures: Literature Review on the Management of Intertrochanteric Fractures

OrthoPedia: Intertrochanteric Fractures: Literature Review on the Management of Intertrochanteric Fractures

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

FiberTape® Sternal Closure for Rib Approximation After Thoracotomy Incisions

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

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