Arthrex Blog - Arthrex Blog en Tue, 28 Jul 2020 05:44:25 GMT Tue, 28 Jul 2020 05:44:25 GMT 60 Pointers & Pearls: Superior Capsular Reconstruction (SCR) Using Knotless SutureTak? Anchors <h4><strong><em> <img alt="Adams" class="pull-left" src="" style="padding: 7px;" width="150" />Featuring Christopher Adams, MD</em></strong></h4> <h5><strong><em>Vice President of Global Education</em></strong><br /><strong><em>Arthrex, Inc.</em></strong></h5> <p>&nbsp;</p> <p>Chris Adams, MD, provides pointers and pearls for SCR repair with knotless SutureTak anchors for medial graft fixation, featuring tips on glenoid&nbsp;anchor insertion, ArthroFLEX&reg;* dermal allograft suture passage, graft delivery and final construct:<br /><br /></p> <p> <img alt="SCR" class="pull-right" src="" style="padding: 7px;" width="300" /></p> <p><span style="text-decoration: underline;">Glenoid Anchor Insertion:</span></p> <ul> <li>Spinal needles can be used to identify the angles of anchor insertion to span the superior aspect of the glenoid to avoid&nbsp;convergence of the anchors and glenoid face perforation.</li> <li>Three knotless SutureTak anchors are inserted percutaneously&nbsp;and their suture limbs remain outside the corresponding portals.</li> </ul> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> <p> <img alt="SCR" class="pull-right" src="" style="padding: 7px;" width="300" /></p> <p><span style="text-decoration: underline;">ArthroFlex Dermal Allograft Suture Passage:</span></p> <ul> <li>A 12-mm PassPort Button&trade; cannula is used to help&nbsp;with suture management and also smoothly deliver&nbsp;the graft into position.</li> <li>The FiberTape&trade; sutures are retrieved first and passed&nbsp;through their prepared locations on the graft.</li> <li>Each knotless SutureTak suture and shuttle loop is&nbsp;retrieved out the cannula. The suture is passed in a&nbsp;mattress configuration through the graft then loaded&nbsp;into the shuttle loop and pulled through the anchor&nbsp;and back out of the corresponding portal.</li> </ul> <p>&nbsp;</p> <p>&nbsp;</p> <p><br /> <img alt="SCR" class="pull-right" src="" style="padding: 7px;" width="300" /></p> <p><span style="text-decoration: underline;">Graft Delivery and Final Construct:</span></p> <ul> <li>A controlled delivery, tensioning each knotless&nbsp;SutureTak suture strand, removing slack until&nbsp;the graft is secure to the glenoid.</li> <li>An anterior lateral side-to-side stitch is passed&nbsp;between the rotator cuff cable and graft&nbsp;without over constraining the shoulder.</li> </ul> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> <p>To view the cadaveric&nbsp;video highlights, visit&nbsp;<a href=""></a></p> <p><a href=""> <img alt="SCR video" class="pull-left" src="" style="padding: 7px;" width="500" /></a></p> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> <p>*ArthroFLEX is a registered trademark of LifeNet Health.</p> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> Kristin Bartlett In the Loop: ACL Primary Repair <h5><strong><em>Biocomposite SwiveLock&reg;&nbsp;</em></strong><strong><em>Anchor and&nbsp;Labral Scorpion&trade; Suture Passing Technology</em></strong></h5> <p>&nbsp;</p> <p>There has been a recent resurgence of interest in the possibility of primary repair as the treatment for certain patterns of ACL rupture. Historically, the technique of primary ACL repair was largely abandoned by the mid-1990&rsquo;s due to marginal clinical outcomes. However, careful analysis of the older data reveals that certain subgroups, especially proximal tears with good tissue quality, had better clinical outcomes than the group as a whole.<sup>1</sup></p> <table style="border-collapse: collapse; width: 100%;" border="0"> <tbody> <tr style="height: 18px;"> <td style="width: 33.3333%; height: 18px;"> <p><em> <img alt="in the loop" class="pull-center" src="" style="padding: 0px;" width="200" /></em></p> </td> <td style="width: 33.3333%; height: 18px;"> <p><em> <img alt="in the loop" class="pull-center" src="" style="padding: 0px;" width="200" /></em></p> </td> <td style="width: 33.3333%; height: 18px;"><em> <img alt="in the loop" class="pull-center" src="" style="padding: 0px;" width="300" /></em></td> </tr> <tr style="height: 198px;"> <td style="width: 33.3333%; height: 198px;">Suture passage through the ACL tissue begins at the intact portion&nbsp;of the ligament and progresses towards the avulsed end. Begin by&nbsp;passing a #2 FiberWire&reg; suture using the Labral Scorpion suture&nbsp;passer. After the first pass, alternate passes with opposite ends,&nbsp;thus creating a Bunnell-type stitch pattern. In a normal length&nbsp;ACL, a total of 2-3 passes can be performed with each limb of the&nbsp;FiberWire suture. The final bite should exit the avulsed end of the&nbsp;ligament to ensure that the tissue sits down flush to the repair site.</td> <td style="width: 33.3333%; height: 198px;">The same technique is performed using a #2 TigerWire&reg; suture. As&nbsp;more passes are performed, the risk of transecting already placed&nbsp;sutures increases. Once the Scorpion suture passer is placed for&nbsp;a suture pass, the surgeon should get tactile feedback of increased&nbsp;resistance attempting to pass the suture if he or she is intersecting&nbsp;a previously placed stitch. If this occurs, the Scorpion suture passer&nbsp;should be redirected and suture passage reattempted. Again, the&nbsp;final bite should exit the avulsed end of the ligament to ensure that&nbsp;the tissue sits down flush to the repair site.</td> <td style="width: 33.3333%; height: 198px;">Once the sutures are passed, and control of the stump has been&nbsp;achieved, the sutures are parked out an accessory stab incision to&nbsp;retract the ligament away from the reattachment site. This allows&nbsp;both the ligament tissue and the sutures to stay out of harm&rsquo;s way&nbsp;while the reattachment site can be prepared with a shaver, a burr&nbsp;or a PowerPick&trade; resector (inset).</td> </tr> <tr style="height: 18px;"> <td style="width: 33.3333%; height: 18px;"><em> <img alt="in the loop" class="pull-center" src="" style="padding: 0px;" width="200" /></em></td> <td style="width: 33.3333%; height: 18px;"><em> <img alt="in the loop" class="pull-center" src="" style="padding: 0px;" width="200" /></em></td> <td style="width: 33.3333%; height: 18px;"><em> <img alt="in the loop" class="pull-center" src="" style="padding: 0px;" width="200" /></em></td> </tr> <tr style="height: 18px;"> <td style="width: 33.3333%; height: 18px; text-align: left;">Create an accessory inferomedial portal that will allow placement&nbsp;of the suture anchors directly into the femoral footprint. Through&nbsp;this portal, with the knee in flexion, 4.5 mm x 20 mm drill holes&nbsp;can be made to place the anchors. The anchor pattern should be&nbsp;optimized depending on the pattern of tear, much like a rotator&nbsp;cuff repair. This will be an intraoperative decision. <em><strong>Note: Some&nbsp;surgeons prefer to visualize the ACL femoral footprint via&nbsp;the medial portal to optimize visualization and placement&nbsp;of the drill holes and anchors.</strong></em></td> <td style="width: 33.3333%; height: 18px; text-align: left;">Load the sutures into the eyelet of the 4.75 mm SwiveLock&nbsp;anchor. Introduce the SwiveLock anchor through the medial&nbsp;portal, insert into the ACL footprint and tension the SwiveLock&nbsp;sutures. Advance the driver into the bone socket until the anchor&nbsp;body contacts bone. Advance the screw by holding the thumb&nbsp;pad as the inserter handle is turned clockwise.</td> <td style="width: 33.3333%; height: 18px; text-align: left;">When the SwiveLock anchor is fully implanted, the eyelet of&nbsp;the anchor is fully seated in the socket by the body of the screw&nbsp;portion of the anchor and the sutures are fixated by the pressure&nbsp;of the screw. Unwind the tip retention suture from the cleat at&nbsp;the back of the driver handle. Remove the driver. Pull one limb of&nbsp;the retention suture to fully remove it from the implant. Cut the&nbsp;free suture ends with an open-ended suture cutter so that they&nbsp;are flush with the edge of the bone socket.</td> </tr> </tbody> </table> <p>&nbsp;</p> <p><sup>1. van Eck CF, Limpisvasti O, ElAttrache NS. Is there a role for internal bracing and repair of the anterior cruciate ligament?<br />A systematic literature review [published online August 1, 2017]. <em>Am J Sports Med</em>. doi:10.1177/0363546517717956.</sup></p> Kristin Bartlett What's in My Bag? Benefits of Synergy MSK? Ultrasound Imaging <h4><em> <img alt="Limpisvasti" class="pull-left" src="" style="padding: 10px;" width="150" />Featuring Orr Limpisvasti, MD</em></h4> <p><em>Anaheim Ducks Hockey Team</em><br /><br />Orr Limpisvasti, MD, is a sports medicine surgeon and the medical director for the&nbsp;Anaheim Ducks hockey team. He also serves as an orthopedic consultant to many&nbsp;other professional athletes and sports teams. Here, Dr. Limpisvasti talks with us&nbsp;about ultrasound and specifically, the benefits of the wireless Synergy MSK&nbsp;ultrasound, a handheld, wireless ultrasound that transmits real-time images to&nbsp;an iOS or Android mobile device.<br /><br /><br /><strong>Q. How has ultrasound helped you treat your patients?</strong><br />A. Ultrasound provides a non-radioactive modality for visualizing superficial structures in real-time. Ultrasound has allowed me to expand my treatment options and improve my injection technique; I have increased accuracy as I am able to visualize the medication as it is being delivered&nbsp;into the desired location. My diagnostic capabilities have improved significantly as well with immediate visualization of soft-tissue pathologies&nbsp;that drive treatment decisions without waiting for 'scheduled' imaging. I am able to effectively monitor soft-tissue healing intermittently to refine&nbsp;and often speed up the rehabilitation process post-surgery or injury. My patients immediately see value in the technology and are engaged in the&nbsp;treatment plans.</p> <p>&nbsp;</p> <p><strong> <img alt="MSK" class="pull-right" src="" style="padding: 5px;" width="250" />Q.What advantages do you see with Synergy MSK ultrasound?</strong><br />A. The Synergy MSK ultrasound with its increased portability and quick setup improves workflow compared to larger ultrasound units as it&nbsp;doesn&rsquo;t require staff time to set up and move a bulky machine. With the iPad as the interface, it&rsquo;s easy to use and minimizes the button fatigue&nbsp;of more complex ultrasound systems on the market today. Patients are impressed by being able to visualize their pathology on an iPad and see&nbsp;real-time what is going on. With the current price point, my colleagues and I can better access an ultrasound unit and avoid scheduling issues.<br /><br /><br /><strong>Q.How has ultrasound helped with your current care of sports teams and professional athletes?</strong><br />A. The portability of the Synergy MSK ultrasound makes it ideal for the care of sports teams because it can be taken on road trips and off-site destinations. Now I have the ability to diagnose in the training room whether at home or on the road. Increasing the availability of ultrasound&nbsp;allows for monitoring of healing and performing diagnoses of common contact injuries throughout the course of the season and post-season.&nbsp;Synergy MSK ultrasound allows me to provide improved care for professional athletes and provide teams with more information for making&nbsp;quick decisions.</p> <p>&nbsp;</p> <p><strong> <img alt="MSK handheld" class="pull-left" src="" style="padding: 5px;" width="250" />Q.What technical pearls can you offer for learning to read ultrasound?</strong><br />A. To improve my acumen with ultrasound, I often compare MRI scans that I would normally perform with new live-time ultrasound. I always compare any pre-op MRI scans to ultrasound&nbsp;in the OR prior to surgery to gain valuable feedback. Using direct comparison of ultrasound and&nbsp;arthroscopic surgical findings has also provided a means for improving diagnostic accuracy.<br /><br /><br /><strong>Q.What other areas could possibly be impacted by using Synergy MSK&nbsp;ultrasound?</strong> <br />A. With Synergy MSK ultrasound, the increased potential applications are numerous. Some that come to mind are the ability to use the system for procedures that require C-arms to&nbsp;be brought into the OR. The ultrasound would also work well for assisting in regional&nbsp;anesthesia and helping to manage certain complications in recovery such as hematomas,&nbsp;urinary retention and DVT.</p> Kristin Bartlett A Patient’s Story: “My surgery saved me, emotionally.” <p> <img alt="DerrickRichardson" class="pull-left" src="" style="padding: 5px;" width="250" />As a lifelong athlete, 35-year-old Derrick Richardson was devastated when he heard &ldquo;You&rsquo;re done. You can&rsquo;t throw a ball anymore&rdquo; from the first surgeon who looked at his injured shoulder in the summer of 2015. &ldquo;It was one of the most emotional moments of my life. I was in tears, thinking that I&rsquo;d never be able to play catch with my kids,&rdquo; Derrick said.&nbsp;</p> <p>From the time he was 15 years old he had played baseball, football and even swam competitively. Being an athlete was a big part of his life. Unfortunately, so were the injuries that came with it. At 25 years old, he had already had two shoulder surgeries and started noticing arthritis. Soon after, he cut back on the sports he played and focused instead on coaching high school baseball.</p> <p> <img alt="DerrickRichardson" class="pull-right" src="" style="padding: 5px;" width="200" />But changing his activity level didn&rsquo;t stop his pain. By the second year of coaching, Derrick started noticing daily pain in his shoulder and was waking up four to five times a night and sometimes his hand would be numb. He went to see a surgeon who gave him bad news. Derrick explained, &ldquo;He said I was too young for a new shoulder and suggested rehab, cortisone shots and worst of all&mdash;told me I couldn&rsquo;t throw ball with my kids.&rdquo; That&rsquo;s when Derrick sought out a different surgeon, Dr. Anthony Romeo, who had performed a previous surgery on him. And for the first time in a long time Derrick felt hopeful when Dr. Romeo told him, &ldquo;We have a shoulder meant for guys like you. You&rsquo;re not going to throw a ball like you used to but you&rsquo;re going to be active again. You&rsquo;re going to have a good life.&rdquo;</p> <p>That&rsquo;s when Derrick first learned about the <a href=""><u>Univers&trade; Apex</u></a>, a total shoulder replacement implant from Arthrex that is specially designed so the surgeon can more accurately recreate the patient&rsquo;s normal shoulder position.</p> <p> <img alt="DerrickRichardson" class="pull-left" src="" style="padding: 5px;" width="175" />Dr. Romeo explained, "Patients like Derrick are often told they are too young for a shoulder replacement.&nbsp;They live with pain and a poor quality of life during some of the most important years of their young life. Fortunately, advances in shoulder replacement like the Univers Apex include the ability to remove the arthritis and replace the joint with a new ball and socket that works like a normal joint, helping the surrounding muscles and tendon heal and return to normal function.&nbsp;Arthrex innovation allows me to offer these fantastic solutions even at Derrick's young age."</p> <p> <img alt="DerrickRichardson" class="pull-right" src="" style="padding: 5px;" width="250" />So at almost 34 years old, Derrick had surgery in January of 2016 with his family supporting him every step of the way. His 8-year-old daughter helped him through six months of rehab by getting her own set of therapy bands and doing exercises with him. And his 4-year-old son checked his scar daily, telling him &ldquo;It&rsquo;s looking good.&rdquo;</p> <p> <img alt="Derrickxray" class="pull-left" src="" style="padding: 5px;" width="200" />And today things are looking good for Derrick. He&rsquo;s throwing a ball, coaching, playing with his kids and happy to share his story. In fact, he&rsquo;s got a conversation starter right on his cell phone&mdash;his wallpaper is an x-ray of his implant. Derrick said, &ldquo;I love talking to people about it. They can&rsquo;t believe I&rsquo;m back to doing what I&rsquo;m able to do.&rdquo;</p> <p>Now looking back, he is happy at how his story ended, &ldquo;The surgery emotionally saved my life, because I can do what I love to do and live the way I want to live without pain.&rdquo;</p> <p><em>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; </em></p> <p><em>The views expressed in this article reflect the experience and opinions of those involved and do not necessarily reflect those of Arthrex, Inc. This is not medical advice from Arthrex.&nbsp;</em><em>Postoperative management is patient specific and dependent on the treating professional&rsquo;s assessment. Individual results will vary and not all patients will experience the same postoperative activity level and/or outcomes. Patient photography is used with express, written consent of the patient or their legal guardian.</em></p> <p>&nbsp;</p> <p>&nbsp;</p> Danielle Batsios 2016 What's New Year in Review Top Trending Videos <p> <img alt="WhatsNew" class="pull-left" src="" style="padding: 5px;" width="500" /></p> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> <p>In celebration of the past year of Arthrex innovations, our fourth annual anniversary editions of our "What's New" email newsletters will highlight the top 12 features over the past year, including our most popular surgical technique videos, presentations and demonstrations by leading orthopaedic surgeons from around the world. The year&rsquo;s top 12 features have been selected based on the number of visits these assets obtained throughout the year by your peers.</p> <p>Our newsletter family of What&rsquo;s New&nbsp;emails specifically focus on content in the areas of arthroscopy and sports medicine, arthroplasty, hand and wrist surgery, foot and ankle surgery, orthopaedic imaging technology, endoscopic imaging technology, orthobiologics and research and education. If you&rsquo;re not already subscribed to What&rsquo;s New or would like to update your subscription preferences per specialty, <a href="">click here</a>.</p> <p><strong>You can also stay up to date on our innovations by:</strong></p> <ul> <li> <p>Visiting the&nbsp;<a href="">front page of</a> for new features daily</p> </li> <li> <p>Following us on Twitter&nbsp;<a href="">@ArthrexWhatsNew</a></p> </li> <li> <p>Subscribing to our <a href="">What&rsquo;s New in Orthopaedics Top Tending Videos YouTube Channel</a></p> </li> </ul> <p>Stay tuned for even more exciting technology updates from Arthrex in 2017, continuing our mission of "Helping Surgeons Treat Their Patients Better&trade;" through innovations in orthopaedics!</p> Danielle Batsios Adolescent Lateral Femoral Trochlea Chondral Fragment Fixed with Poly-L-Lactic Acid Arthrex Chondral Darts <p><strong>by&nbsp;John K. Morris, MD, Alexander E. Weber, M., Mark S. Morris, MD</strong><br /><strong> Department of Orthopedics, University of Michigan Medical Center, Ann Arbor, MI and the Section of Orthopedics, St. Joseph Mercy Hospital, Ann Arbor, MI</strong></p> <p>Large chondral injuries without attached bone are uncommon. We report the case of a 14-year-old who developed a stress reaction between the bone and overlying articular cartilage predominantly of the anterior lateral femoral condyle during a week-long basketball camp, resulting in complete displacement of a 2.5 &times; 2.5-cm full-thickness articular cartilage lesion.</p> <p>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</p> <p style="line-height: 200%;"> <img alt="Arthrex, Inc." class="pull-left" src="" style="padding: 5px;" width="200" /></p> <p class="BodyA" style="line-height: 200%;"> <img alt="Arthrex, Inc." class="pull-left" src="" style="padding: 5px;" width="200" /></p> <p class="BodyA" style="line-height: 200%;"> <img alt="Arthrex, Inc." class="pull-left" src="" style="padding: 5px;" width="200" /></p> <p> <img alt="medially" class="pull-right" src="" style="padding: 5px;" width="200" />Three weeks after the initial injury the patient was brought to the operating room for a diagnostic arthroscopy and open arthrotomy at which time the cartilage-free fragment was returned to its donor site and fixed with poly-L-lactic acid (PLLA) Arthrex chondral darts. Considerable de-lamination of the shoulders of the defect was noted on the pre-op MRI and at the time of surgery, suggesting a prodromal stress reaction. A V-shaped area of undermined cartilage in the central trochlea was too thin for dart fixation so the cartilage was excised and the area microfractured. Four darts secured the main fragment and one dart was inserted in an undermined area medially.</p> <p>Despite no underlying subchondral bone on the free cartilage fragment, the injury healed. The patient had return of full knee motion and strength. Three-month post-operative&nbsp;magnetic resonance imaging demonstrated healed cartilage.</p> <p> <img alt="healed articular fragment at 3 months post-op" class="pull-left" src="" style="padding: 5px;" width="200" /></p> <p>At one year of clinical follow-up the patient had no clinical sequelae from the initial injury and had returned to competitive basketball.</p> <p>The current case demonstrates a unique presentation of an isolated chondral injury successfully managed with Arthrex PLLA chondral darts. The chondral darts worked well, allowing a large full-thickness piece of articular cartilage to be successfully repaired back to its origin. Important characteristics of this implant that lead to successful healing include the ease of implantation, the flushness of the head to the articular surface, the security of the dart without implant back out, and the lack of biologic reactivity. Biologic reactivity to biodegradable implants and leaving the implant proud or backing out of the implant head have all led to iatrogenic damage and poor outcomes with previous implants. Lastly, the chondral dart does not require an additional surgery for implant removal. The Arthrex chondral dart was an invaluable resource that allowed a successful outcome for our patient.</p> <p>&nbsp;</p> Danielle Batsios The Mini TightRope: Not Just for Arthritis by Steven S. Shin, MD <p><strong> <img alt="Dr. Steven Shin" class="pull-left" src="" style="padding: 7px;" width="150" /></strong></p> <p><strong>Q: What made you want to use the Mini TightRope for something other than thumb basal joint arthritis?</strong></p> <p>A: I treat many high-level athletes in my practice, including competitive athletes. One day, I got a call that an athlete sustained a Bennett fracture-dislocation of his right (dominant) thumb. The Bennett fragment was very small. He begged me to do something to allow him to get back to playing earlier than the usual six weeks. Normally, I would have pinned the fracture and the CMC joint and then placed the thumb into a cast for four weeks before allowing him to move the thumb. One would expect the usual downsides of this option: risk of pin site infection, disuse atrophy, stiffness, etc. I&rsquo;ve become very familiar with the Mini TightRope, which I&rsquo;ve used for my revision thumb CMC joint arthroplasties; I&rsquo;m still a fan of the LRTI technique with tenodesis screw for my primary arthroplasties. The Mini TightRope does such a good job of suspending the thumb metacarpal after excision of the trapezium, so why not use this for cases of thumb CMC joint instability? So I offered this option to the player and he jumped at this option before I could even explain it to him!</p> <p><strong>Q: Can you tell us about the surgery?</strong></p> <p>It&rsquo;s the same approach and technique as the suspensionplasty for thumb CMC joint arthritis, except the trapezium is retained. I first passed a #2 FiberWire suture around the base of the thumb metacarpal, essentially lassoing the fragment to reduce it into place. The knot was tied dorsally and buried in the thenar muscles. However, there was still some instability at the CMC joint, so I proceeded with placing the Mini TightRope across the bases of the thumb and index metacarpals, and this gave excellent stability to the thumb CMC joint. I then imbricated the dorsal capsuloligamentous complex and closed the incision.</p> <p> <img alt="preoperative x-rays" class="pull-left" src="" style="padding: 7px;" width="450" /></p> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> <p><strong>What happened postoperatively?</strong></p> <p>Due to the stability of the joint following the Mini TightRope, I allowed him to start&nbsp;moving his thumb within a few days.</p> <p> <img alt="preoperative x-rays" class="pull-left" src="" style="padding: 7px;" width="275" /></p> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> <p>&nbsp;</p> <p><strong>Can you discuss any other cases where you have used the Mini TightRope for a similar indication?</strong></p> <p>I performed this technique in the dominant thumb of a professional athlete as well. He had a larger Bennett fragment that was amenable to screw fixation, but due to some persistent instability at the thumb CMC joint following the fracture repair, I added the Mini TightRope as well.</p> <p>&nbsp;</p> <p>&nbsp;</p> Danielle Batsios Radial Collateral Ligament Reconstruction with DX SwiveLock? SL by Damon Adamany, MD <p><strong> <img alt="RCL" class="pull-right" src="" style="padding: 7px;" width="150" />Q: Performing a&nbsp;Radial Collateral Ligament (RCL) reconstruction with <em>Internal</em>Brace augmentation with the 3.5 DX SwiveLock SL is a new variation on what you have done in the past. Can you give us a brief overview of what you were doing and how you are changing your technique?</strong></p> <p><strong>A:</strong> I was using the Arthrex 3 x 8 mm tenodesis screws with a palmaris graft for my reconstructions of both the radial and ulnar collateral ligaments of the thumb MCP joint. I still think that technique is solid and works well but have found a few differences that highlight some of the advantages of the new DX SwiveLock SL.&nbsp;</p> <ul> <li>On the radial side, I can incorporate 1.5 mm LabralTape as an <em>Internal</em>Brace augmentation for my biologic graft repair.</li> <li>I like the idea of not having any suture left behind on the ulnar side as I would normally have with using a 3 x 8 mm tenodesis screw technique. The blind tunnel technique of the 3.5 SwiveLock eliminates any concern I had about irritation from the small strand of suture left behind in the pull-through tenodesis technique.</li> <li>If LabralTape is used as an <em>Internal</em>Brace, you do not have to whipstitch or suture your graft. In addition to saving time, LabralTape gives the immediate strength to the construct while the soft tissue repair heals and incorporates.</li> <li>Lastly, there is no need to measure the graft length as is necessary with the standard tenodesis screw reconstruction technique. Tension is achieved by grabbing the tendon with the forked eyelet and bringing it down into the unicortical hole. Any remaining tendon can be cut flush to the bone.</li> </ul> <p>&nbsp;</p> <p><strong>Q: <em>Internal</em>Brace has been gaining popularity for a variety of techniques. Are you changing your post-op protocol to reflect the extra stability?</strong></p> <p><strong>A:</strong> There were times in the past when I was concerned about repair strength or patient compliance and I would temporarily place a K-wire across the MCP joint to help protect the repair for a short period of time. These new techniques and anchors from Arthrex have allowed me to eliminate the need for a K-wire by internally bracing the repairs using 1.5 mm labral tape from Arthrex.</p> <p><strong>Q: Are there any other procedures that you see the 3.5 DX SwiveLock SL being used for?</strong></p> <p><strong>A:</strong> The new 3.5 DX SwiveLock has allowed me to explore improving current techniques that we are using in the upper extremity. Recently, I had a perilunate dislocation with obvious scapholunate ligament rupture. Although I acutely repaired the ligament through drill holes using FiberWire, I worried that my repair might not heal or may not be strong enough. The amount of force per unit area that the ligament and joint see is extremely high and likely accounts for the high rate of failure for many of the techniques that we are trying to utilize to reconstruct and repair this ligament.</p> <p>I repaired the ligament back to the footprint on the lunate through drill holes. I then protected my repair by internally bracing using 1.5 mm LabralTape from Arthrex. I utilized the new 3.5 DX SwiveLock by placing one in the superior proximal pole of the scaphoid, one in the lunate, and then finally one in the&nbsp;very distal, dorsal aspect of the scaphoid. By linking the two bones in this manner with an internal brace I hope to protect the repair long after I remove the K wires that were placed.&nbsp;</p> <p><strong>Q: Do you have anything further to add regarding the new 3.5 DX SwiveLock anchor from Arthrex?</strong></p> <p><strong>A:</strong> It is nice to have the product on the shelf as a bailout option to help me if I run into trouble in a procedure. For instance, although I have not had to have the need to use it in this circumstance, there are definitely some people that are using the new anchor for CMC arthroplasty procedures. I certainly could see the anchor being useful if I had a catastrophic failure during my FCR tendon transfer. One could easily use a free graft and back it up with an internal brace in order to perform a suspensionplasty in that circumstance by utilizing the new Arthrex 3.5 DX SwiveLock anchor.</p> <p> <img alt="RCL" class="pull-left" src="" style="padding: 7px;" width="250" /></p> <p>&nbsp;</p> <p> <img alt="RCL" class="pull-right" src="" style="padding: 7px;" width="250" /></p> <p>&nbsp;</p> <p> <img alt="RCL" class="pull-left" src="" style="padding: 7px;" width="250" /></p> <p>&nbsp;</p> <p> <img alt="RCL" class="pull-right" src="" style="padding: 7px;" width="250" /></p> Danielle Batsios ACL Primary Repair with Central Augmentation Q&A with Gregory S. DiFelice, MD <p><strong> <img alt="Dr.DiFelice" class="pull-left" src="" style="padding: 7px;" width="120" />Q: At the last Faculty Forum meeting, you presented on your concept of ACL Preservation. Can you discuss what you mean by this?</strong></p> <p><br /><strong>A:</strong> ACL Preservation refers to my approach to the treatment of ACL injuries. It is a novel and progressive approach that focuses on trying to save as much of the native ligament remnant as possible. The current standard of care is reconstruction that generally resects the ligament remnant and reconstructs the ligament with one of multiple graft choices. With my approach, I use reconstruction as a last resort. For many of my patients I am able to save most, or all, of their native ligament with several techniques that I have developed in collaboration with Arthrex. (1, 2)</p> <p><br /><strong>Q: In your last blog entry you updated us on your ACL Primary Repair technique. Can you discuss the augmentation technique that you use?</strong></p> <p><br /><strong>A:</strong> My approach of preserving the native ACL tissue started with my work on ACL Primary Repair (1) for proximal avulsion tears. As my skills and results improved, I became frustrated that I couldn&rsquo;t repair more tears. Far more tears are proximal 20% tears, than are avulsion tears, and after attending ArthroLondon in 2012 and hearing Dr. van der Merwe&rsquo;s lecture on Biologic ACL Reconstruction, I had an epiphany. It dawned on me that I could combine his technique of augmenting the ligament with my technique of repairing the remnant to avoid the rather high rate of Cyclops lesions (a ball of scar tissue created by the sagging ligament remnant that blocks knee extension and can cause pain) that can complicate standard augmentation techniques. The resultant technique is called ACL Primary Repair with Central Augmentation and the technique video can be viewed on (2).</p> <p><br /><strong>Q: Are there any differences between augmentation and reconstruction besides preserving the remnant?</strong></p> <p><br /><strong>A:</strong> Yes, augmentation is a more conservative approach than reconstruction in many ways. Preserving the remnant maintains the native ligament tissue, nerve endings and blood supply with obvious benefit. Thus, it is not necessary to use such a large graft like is used in the typical reconstruction. Typical reconstructions create 10 mm tunnels in the femur and tibia to place the graft into. Using a 7 or 8 mm graft in a reconstruction generally makes the surgeon somewhat nervous about the graft not being strong enough, however, this is routine in an augmentation. Maintaining the remnant obviates the need to use such a large graft and conserves bone.</p> <p><br /><strong>Q: For what percentage of your patients are you able to use your ACL Preservation approach?</strong></p> <p><br /><strong>A:</strong> Currently, my ACL Preservation approach encompasses ACL Primary Repair and ACL Repair with Central Augmentation as mentioned. Using this approach, I am able to save most, or all, of the native ligament for approximately 50% of my patients. This, to me, is a tremendous advantage over the standard reconstructive approach in that native tissues are preserved with all of the concomitant benefits. At the same time, very few surgical bridges are burned, such that revision surgery, when needed, is almost like performing a primary reconstruction.</p> <p><br /><strong>Q: Have you noticed a difference in the postoperative course and rehab with augmentation versus reconstructions?</strong></p> <p><br /><strong>A:</strong> Interestingly, I have. At first, I didn&rsquo;t think that there would be much of a difference between the two techniques since tunnels were being drilled in both cases. However, anecdotally, I have definitely noticed that the augmentations seem to have less pain and swelling and a more stable/normal knee subjectively and objectively in follow-up. I explain to my patients that instead of having a &ldquo;one size fits all&rdquo; approach to ACL surgery that is currently the standard of care in my mind, I offer a customized approach to ACL injury. I utilize small (repair), medium (augmentation) and large (reconstruction) surgeries, depending on the nature of the ligament injury and the quality of the remnant tissue. For each patient, the final decision as to which procedure is best suited for them is made on the table when the tear type and tissue quality are determined intraoperatively.</p> <p><br /><strong>Q: As ACL Preservation seems like a rather intuitive approach to ACL injury, why do you think such an approach wasn&rsquo;t adopted historically?</strong></p> <p><br /><strong>A: </strong>The answer to that question is best summed up by the old saying &ldquo;hindsight is 20/20.&rdquo; Original attempts at repair were performed open, on all injury types and heterogeneous patient populations that yielded mixed results, at best. This led some authors to move towards augmentations that actually had somewhat more predictable results, even when done open. However, at right about the same time, arthroscopy was coming to the forefront, and in the early days of arthroscopy the technology, the instruments and the surgical skills were not sophisticated enough to preserve the remnant. I like to say that the first surgeon to look good performing an arthroscopic ACL reconstruction was the first surgeon to resect the entire ligament so that they could see what they were doing. Once that bridge was burned there was very little discussion about remnant preservation in the literature for the ensuing 25 years or so. Current imaging technology, anatomic and biologic understanding, and both surgical technology, and skill, have enabled us to reinvigorate the discussion of what was, in my mind, the right idea at the wrong time.</p> <p><strong>References:</strong><br />1. <a href="">ACL Preservation: Early Experience Presentation Video</a><br />2. <a href="">ACL Preservation with Central Augmentation Using the FlipCutter&reg; and TightRope&reg; RT Presentation</a></p> <p>&nbsp;</p> Danielle Batsios Meniscal Repair Using Knee Scorpion? Suture Passer <p>by&nbsp;John W.&nbsp;Xerogeanes, MD&nbsp;</p> <p> <img alt="Dr.X" class="pull-left" src="" style="padding: 7px;" width="100" />We all know that meniscal repair is a very important procedure to perform effectively, and we&rsquo;re all also keenly aware of this procedure&rsquo;s challenges. While we have many options in our arsenal, the options for tears of the posterior third of the menisci remain less than optimal. This is especially true for tears of the meniscal root as well as fenestrated tears of the posterior third of the menisci.&nbsp; The Knee Scorpion provides an answer for these tears. It is easy to use, extremely reliable, reusable and cost effective.</p> <p> <img alt="kneescorpion" class="pull-right" src="" style="padding: 7px;" width="200" />The Knee Scorpion&trade; passes and retrieves sutures just like the Scorpions for the rotator cuff and labrum, therefore those that have used Scorpions before will already be familiar with using the device. It works with standard 2-0 FiberWire&reg; suture as well as 0 FiberWire&trade;. The device&rsquo;s curvature and low profile allows the surgeon to easily get under the condyles and access the posterior third of the meniscus.&nbsp; Because of its small diameter, I often make auxiliary poke holes to obtain the perfect angle to the meniscus when needed.&nbsp;</p> <p>I use it to place sutures through avulsed meniscal roots as well as to place circumferential sutures around complex longitudinal tears of the posterior third of the lateral meniscus.&nbsp; It also works well to reinforce all-inside Meniscal Cinch&trade; repairs when needed.</p> <p>It is an ideal device to keep in my meniscal repair tray, and because of its versatility, I can use it with or without other meniscal tear devices.&nbsp;</p> Danielle Batsios BreakThrough with Chris Adams, MD - SCR <p> <img alt="BreakThrough" class="pull-right" src="" style="padding: 7px;" width="250" /></p> <p>Hundreds of surgeons from around the world took part in the inaugural <em><strong>BreakThrough with Chris Adams, MD</strong></em> webcast on August 18, a novel web program that brought leading surgeons together to present and discuss how the most medically significant technology innovations are changing the way they treat their patients in orthopaedic surgery.</p> <p> <img alt="BreakThrough" class="pull-left" src="" style="padding: 7px;" width="250" />The first broadcast of <em><strong>BreakThrough</strong></em> included host and Arthrex Medical Education Director Chris Adams, MD, as well as guests Stephen Burkhart, MD, and Alan Hirahara, MD, who shared their experiences and discussed the benefits of the Superior Capsular Reconstruction (SCR) technique for patients with massive, irreparable rotator cuff tears of the shoulder. SCR represents a new arthroscopic reconstruction technique option that has quickly become an exciting new alternative to more invasive procedures like reverse total shoulder arthroplasty.</p> <p>&ldquo;With our new webcast series&nbsp;<strong><em>BreakThrough</em></strong>, we've created an interactive learning experience for viewers showcasing an expert panel discussing cutting-edge topics and answering the audience&rsquo;s questions in real time,&rdquo; said Chris Adams, MD. &ldquo;It's very exciting to be able to introduce and educate the medical community on new surgical techniques and developments from Arthrex. With a successful turn out for the premiere broadcast, we look forward to building momentum and sharing additional emerging technologies in future episodes. Stay tuned!&rdquo;&nbsp;</p> <p>With hundreds of new Arthrex product innovations released each year,&nbsp;<strong><em>BreakThrough</em></strong> provides a unique platform for laser focused, in-depth discussions on cutting-edge technologies and techniques that will be significant in the treatment breakthroughs for surgeons and their patients around the globe.</p> <p>You can view an&nbsp;<a href="">on-demand version of this broadcast on our website </a>or <a href="">a complete playlist, including this broadcast, at our <em><strong>BreakThrough</strong></em> YouTube channel</a>.</p> <p>&nbsp;</p> Danielle Batsios Mark Campbell, MD - Double Compression Plates <p> <img alt="Mark Campbell" class="pull-left" src="" style="padding: 8px;" width="150" /></p> <p class="p1">Post-traumatic arthritis following a Lisfranc complex injury is a common&nbsp;occurrence. Although the injury itself predisposes to this complication,&nbsp;popular fixation modes using transarticular screw stabilization result&nbsp;in iatrogenic damage to the joint and results in another possible&nbsp;mechanism of post-traumatic DJD. This complication often results&nbsp;in the need for tarsal metatarsal joint fusion as the definitive treatment.</p> <p class="p1">This case involved a 32-year-old male status post motocross injury.&nbsp;Three years earlier he was treated with an ORIF of his Lisfranc&nbsp;injury using transarticular screws. Patient has continued to have&nbsp;pain. Radiographs suggested, and CT scan confirmed post&nbsp;traumatic degenerative changes.</p> <p class="p1">Treatment consisted of hardware removal and fusion of the 1st, 2nd,&nbsp;and 3rd TMT articulations. Fusion preparation consisted of meticulous&nbsp;joint preparation along with the addition of StimuBlast<span class="s1">&reg; </span>DBM mixed&nbsp;with bone marrow concentrate with the Arthrex Angel<span class="s1">&reg; </span>system. Fixation&nbsp;was obtained using three Arthrex<span class="s1">&reg; </span>Double Compression Plates with the&nbsp;addition of an LPS 4.0 partially threaded Cannulated screw.</p> <p class="p1">The Arthrex<span class="s1">&reg; </span>Double Compression Plate system is a revolutionary&nbsp;fixation construct that allows maximal surgical compression across&nbsp;fusion sites. The hallmark of this design is the improved compression&nbsp;achieved using the double compression mechanism. Initial compression&nbsp;is achieved using standard compression hole principles. Additional&nbsp;secondary compression is achieved through the bridge &ldquo;arms&rdquo; of the&nbsp;plate construct. This double compression mechanism allows the&nbsp;surgeon maximal compression potential with direct visual and tactile&nbsp;controlled feedback.</p> <p class="p1"> <img alt="DoubleCompressionPlates" class="pull-right" src="" style="padding: 8px;" width="260" /></p> <p class="p1">The low profile design allows decreased risk of irritation in areas&nbsp;with little soft tissue coverage such as the dorsum of the foot. Once&nbsp;the locking screw is placed flush to the bone, the nonlocking screw&nbsp;will provide not only initial compression, but will mold the plate flush&nbsp;over the osseous bed.</p> <p class="p1">The fixation system&rsquo;s simplicity, ease-of-use and multiple plate&nbsp;configurations allow these plates to be used for talonavicular,&nbsp;calcaneocuboid, transverse tarsometatarsal, forefoot, and hindfoot&nbsp;arthrodesis sites.</p> <p class="p1">The improved overall compression achieved with the double&nbsp;compression mechanism allows for the maximal potential for&nbsp;bone-to-bone opposition, which is known to be the most critical&nbsp;factor in overall construct stability. Clinically, this can translate to&nbsp;improved fusion rates for simple and complex arthrodesis throughout&nbsp;the foot and ankle.</p> <p class="p1">&nbsp;</p> <p class="p1"><em>The views expressed in this post reflect the experience and opinions of the presenting surgeon and do not necessarily reflect those of Arthrex Inc.</em></p> Diana Wydysh ACL Preservation Q&A with Gregory S. DiFelice, MD <p><strong> <img alt="Dr.DiFelice" class="pull-left" src="" style="padding: 7px;" width="120" />Q: It has been about a year since your last blog entry, what is the update with regard to ACL Preservation?</strong></p> <p>A: There are a number of interesting things that have occurred since we last spoke in this forum. First of all, my patients continue to grow in numbers and in successful outcomes. I have performed 38 arthroscopic ACL Primary Preservations for isolated ACL injured patients to date, and probably closer to 50 if you include those patients with ACL avulsions in the multiple ligament injured knee (MLIK) setting. I continue to run at right around the 90% clinical success mark. The failures, except for one of the early patients who failed at around 3 months, occurred after repeat trauma at more than a year postoperatively playing soccer and rugby.</p> <p>Secondly, I have modified the technique slightly after considering the basic science research of four separate papers that showed that adding a suture construct connecting the femur to the tibia in parallel with the repair improves the early biomechanics (1-4), potentially protecting the early repair. This is essentially the <em>Internal</em>Brace&reg; concept that has been gaining popularity throughout the body since Dr. Mackay introduced it several years ago for the knee MCL. I have used this technique, in various forms, in over half of my ACL Primary Preservation patients.</p> <p>Finally, I presented the two- to six-year (avg. 3.5 years) clinical results of my first 11 patients as an ePoster (5) at the April 2015 Arthroscopy Association of North America (AANA) conference that was held in Los Angeles. In addition, I presented the findings of a bench study comparing my suture anchor primary repair to a conventional transosseous button repair in a simulated active motion cadaveric model as an ePoster (6) at the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) meeting in Lyon, France in June. I also anticipate publishing a series of papers later this year in a high impact factor, peer-reviewed journal; one as a systematic review of ACL repair literature over the last decade and the other as a clinical paper detailing my experience with my first 11 arthroscopic ACL Primary Preservation patients. Hopefully, this will catapult arthroscopic ACL Primary Preservation into the mainstream ACL discussion.</p> <p><strong>Q: What has the response been to your latest research and presentations?</strong></p> <p>A: Since Arthrex released my 2014 Faculty Forum presentation on ACL Primary Preservation, and the subsequent surgical technique video, I have been contacted multiple times by other surgeons who are intrigued by the idea or have tried a few themselves with good results. Arthrex&rsquo;s global reach certainly ignited a buzz regarding this topic. However, let&rsquo;s not forget that the worldwide ACL surgeon community effectively gave up on this concept over 30 years ago. In reality, aside from long-term follow-ups of the original open ACL repair cohorts, there hasn&rsquo;t been a single publication regarding new techniques for ACL Primary Preservation or ACL Primary Preservation outcomes in human beings in over 30 years. Thus, I am excited about the recent ePosters and the forthcoming publications.</p> <p><strong>Q: Do you think this will become a mainstream technique for ACL patients?</strong></p> <p>A: It is unrealistic for me to argue that my early to mid-term results on less than 50 patients will change the mainstream thinking regarding ACL surgery. However, that was never my goal. My goal, first of all, was to do what I felt was right for my patients in my hands. Next, my goal was to share my concept and my experiences in order to start a discussion that, in time, might possibly change our collective approach as groupthink kicks in. It is hard for me to imagine that surgeons will not adopt such a minimally morbid procedure for select patients seeing that no bridges are burned if the repair fails. This cannot be said for modern day ACL reconstruction that has far from perfect results. Admittedly, my numbers are rather low thus far, and there are several things at play here. First of all, I have been very meticulous in my indications by trying to limit the application of the procedure to only those with the perfect Type 1 proximal avulsion type tears. These tears may only represent 5-25% of the tears depending on the practice mix that the surgeon sees. Furthermore, my practice is rather broad in focus, and not limited to only ligamentous injuries of the knee.&nbsp;</p> <p><strong>Q: Even though only a small percentage of patients seem to meet the indications for ACL Primary Preservation in your practice, has your experience thus far changed the way that you approach all patients with ACL injuries?</strong></p> <p>A: Absolutely. First of all, the great majority of my ACL Preservation patients have recovered quickly, and with good outcomes, that I wish that more of my patients met the criteria for repair. I recently saw a patient, my 37<sup>th</sup> repair, back at one-month post-op who illustrates this point well. He detailed that he had full range of motion within one week, and that since one-week post-op, he had been commuting an hour and 15 minutes each way to work via train with a lot of standing and walking. He explained that he didn&rsquo;t have any significant swelling or discomfort after the first week despite these long hours on his feet. Interestingly, he had undergone an autograft BTB on the other leg eight years earlier so he had his own internal control. Needless to say, thus far, he is a believer.</p> <p>Seeing my patients doing so well after Primary ACL Preservation, I became more frustrated when I encountered ACL remnant tissue that wasn&rsquo;t quite long enough to reach the wall. You see, once you get in the habit of saving the ligament if possible, then resecting significant portions of ligament remnant doesn&rsquo;t seem like the right thing to do. It seems that I am not alone in this sentiment as numerous authors, mostly from Europe and Asia, have published on remnant preserving or sparing ACL reconstruction. After seeing Dr. van der Merwe&rsquo;s presentation on &ldquo;Biologic ACL Reconstruction,&rdquo; at ArthroLondon in 2012, I realized that augmenting the ligament remnant with a hamstrings graft had significant theoretical biologic benefit. However, to avoid cyclops lesions that tend to be common when augmenting the remnant, I developed a technique to combine my ACL Primary Preservation technique with his Biologic Augmentation. Arthrex released the surgical technique video last year that describes what I call ACL Preservation with Central Augmentation.</p> <p>In my clinical practice, I have adopted an ACL Preservation approach. Essentially, I attempt &ldquo;Preservation,&rdquo; or &ldquo;Preservation and Augment,&rdquo; in as many torn ACLs as I can so as to customize the surgical approach to the injury pattern. Since I have adopted this approach in September 2012, I have evolved to the current day where I am able to save all or most of the ligament in nearly 50% of patients.</p> <p>&nbsp;</p> <p><strong>References:</strong></p> <p>1. Fleming BC, Carey JL, Spindler KP, Murray MM. Can suture repair of ACL transection restore normal anteroposterior laxity of the knee? An ex-vivo study. <em>J Orthop Res</em>. 2008;26(11):1500-1505. doi: 10.1002/jor.20690.</p> <p>2. Murray MM, Magarian E, Zurakowski D, Fleming BC. Bone-to-bone fixation enhances functional healing of the porcine anterior cruciate ligament using a collagen-platelet composite [Published online ahead of print June 11, 2010]. <em>Arthroscopy</em>. 2010;26(9 Suppl):S49-S57. doi: 10.1016/j.arthro.2009.12.017.&nbsp;</p> <p>3. Fisher MB, Jung HJ, McMahon PJ, Woo SL. Evaluation of bone tunnel placement for suture augmentation of an injured anterior cruciate ligament: effects on joint stability in a goat model. <em>J Orthop Res</em>. 2010;28(10):1373-1379. doi: 10.1002/jor.21141.</p> <p>4. Fisher MB, Jung HJ, McMahon PJ, Woo SL. Suture augmentation following ACL injury to restore the function of the ACL, MCL, and medial meniscus in the goat stifle joint [ published online ahead of print April 6, 2011]. <em>J Biomech</em>. 2011;44(8):1530-1535. doi: 10.1016/j.jbiomech.2011.02.141.</p> <p>5. DiFelice GS, Villegas C. ACL preservation: early results of a novel arthroscopic technique of suture anchor primary ACL repair. Presented at: AANA 2015 Annual Conference; April 23-25, 2015; Los Angeles, CA.<a href=""> </a>Accessed July 14, 2015.</p> <p>6.DiFelice GS, DeLong JM, Villegas C. Suture Anchor vs. drill tunnel primary ACL repair: an in vitro comparison of gap formation. Presented at: ISAKOS 2015 Annual Conference; June 7-9, 2015; Lyon, France.&nbsp;<a href=""></a>.&nbsp;Accessed July 14, 2015.</p> <p>&nbsp;</p> <p>&nbsp;</p> <p><em>The views expressed in this post reflect the experience and opinions of the presenting surgeon and do not necessarily reflect those of Arthrex Inc.&nbsp;This technique may not be applicable to all patients. </em></p> Danielle Batsios Michael Coughlin, MD - Plantar Plate Repair Surgical Tips and Pearls <p> <img alt="Coughlin" class="pull-left" src="" style="padding: 7px;" width="190" /></p> <p class="p1">Dr. Michael Coughlin has noted that in his two year prospective&nbsp;study he is seeing good long term results and high patient satisfaction&nbsp;following direct plantar plate repairs.&nbsp;</p> <p class="p1"><strong>Surgical repair of plantar plate tears using CPR Viper<span class="s1">&trade;</span></strong></p> <p class="p1">Plantar plate tears of the lesser metatarsophalangeal joints are common,&nbsp;and painful conditions that can lead to substantial deformities of the&nbsp;involved digits. Early on conservative treatment may relieve discomfort,&nbsp;but with the passage of time, these conditions tend to worsen with the&nbsp;development of angular deformities of the toes, and in time, development&nbsp;of a fixed hammertoe.</p> <p class="p1">&nbsp;</p> <p class="p1"> <img alt="Plantar Plate" class="pull-right" src="" style="padding: 7px;" width="250" /></p> <p class="p1">The CPR Viper<span class="s1">&trade; </span>is a unique concept that allows exposure of the plantar&nbsp;plate through a dorsal approach without the use of a Weil metatarsal&nbsp;osteotomy. While typically a plantar plate repair necessitates the combined&nbsp;shortening of the involved lesser metatarsal with the plantar plate&nbsp;repair, there are situations where shortening is not necessary. Often an&nbsp;involved 3rd or 4th MTP joint does not require shortening, and in revision&nbsp;cases where an osteotomy has previously been performed, an osteotomy&nbsp;may not be indicated or desired.&nbsp;</p> <p class="p1">When the conditions do indicate shortening, such as a long second&nbsp;metatarsal, a Weil osteotomy may be performed in conjunction with&nbsp;the use of the Mini Scorpion<span class="s1">&trade;</span>.&nbsp;</p> <p class="p1"><strong>Step 1:</strong>&nbsp;The involved MTP joint is approached through a dorsal&nbsp;longitudinal incision and deepened in the interval between the&nbsp;two extensor tendons. The collateral ligaments are taken down&nbsp;from their phalangeal attachment, and a McGlamry elevator is&nbsp;used to release the proximal plantar plate attachments from the&nbsp;metatarsal metaphysis.</p> <p class="p1"><strong>Step 2:</strong>&nbsp;Vertical Kirschner wires are placed in the base of the proximal&nbsp;phalanx and the metatarsal head, and the Arthrex small joint&nbsp;retractor is used to distract the joint. (Typically a 4-5 mm interval&nbsp;is achieved). The plantar plate tear is visualized, and if&nbsp;incomplete, is taken down, completing the tear transversely.&nbsp;(This allows for easier passing of the sutures).</p> <p class="p1"><strong>Step 3:&nbsp;</strong>The Arthrex<span class="s1">&reg; </span>CPR Viper is then used to pass two sets of horizontal&nbsp;FiberWire<span class="s1">&copy; </span>sutures securing the distal plantar plate. These sutures&nbsp;are then passed through two oblique drill holes in the base of the&nbsp;proximal phalanx.</p> <p class="p1"><strong>Step 4:</strong>&nbsp;With the toe held in 20&deg; of plantar flexion, the sutures are tied&nbsp;over the bony bridge. The skin is closed in a routine fashion.&nbsp;(Jastifer and Coughlin* report passing of these sutures without&nbsp;Weil osteotomy in a cadaveric study with 100% success.)</p> <p class="p1">&nbsp;</p> <p class="p1"><em>The views expressed in this post reflect the experience and opinions of the presenting surgeon and do not necessarily reflect those of Arthrex Inc.</em></p> Diana Wydysh Pat Smith, MD, and Tom DeBerardino, MD, Discuss Biomechanical Study of GraftLink? and ACL TightRope? ABS For Tibial ACL Fixation <p> <img alt="GraftLink" class="pull-right" src="" style="padding: 7px;" width="200" />Traditionally, tibial fixation has been described as the &ldquo;weak link&rdquo; for soft tissue graft fixation. Fixation on the tibial side is felt to be inherently weaker due to poorer bone quality compared with the distal femur and graft forces being more in line with the tibial tunnel. All-Inside ACL reconstruction uses sockets, rather than tunnels, in the tibia which makes possible the use of a cortical suspensory device like the ACL TightRope ABS.</p> <p>Our study, "<a href="">Tibial Fixation Properties of a Continuous-Loop ACL Hamstring Graft Construct with Suspensory Fixation in Porcine Bone</a>"&nbsp;in the <em>Journal of Knee Surgery,</em>&nbsp;compared traditional interference screw fixation to cortical fixation using the ACL TightRope ABS and the GraftLink construct. The results showed a statistically significant higher yield and ultimate load for the TightRope ABS/GraftLink group over that of interference screws. Cyclic displacement was statistically similar and well under the 3 mm threshold.&nbsp;</p> <p>&nbsp;</p> <p>Reference:</p> <ol> <li>Smith PA,&nbsp;DeBerardino TM. Tibial&nbsp;Fixation&nbsp;Properties&nbsp;of a&nbsp;Continuous Loop&nbsp;ACL&nbsp;Hamstring&nbsp;Graft&nbsp;Construct&nbsp;with&nbsp;Suspensory&nbsp;Fixation&nbsp;in Porcine&nbsp;Bone [published online ahead of print October 27, 2014].<em>J Knee Surg.</em> doi: 10.1055/s-0034-1394167.</li> </ol> <p>&nbsp;</p> Danielle Batsios What's in My Bag with Alan M. Hirahara, MD, FRCS(C) <p><strong>Joint Preservation with Superior Capsule Reconstruction (SCR)</strong></p> <p><strong> <img alt="Dr.Hirahara" class="pull-left" src="" style="padding: 7px;" width="150" />Q. Is SCR a new technique? What does it do and how are the long-term results?</strong></p> <p><strong>A.</strong> The SCR was pioneered by Dr. Teruhisa Mihata in 2007 for patients with irreparable rotator cuff tears. He recently published 24-51 month follow-up on 24 of his patients, showing outstanding outcomes in pain, ASES scores and acromial-humeral distance measurements. This technique recreates a superior capsule to keep the humeral head reduced in the glenoid by attaching tissue from the glenoid to the greater tuberosity.</p> <p>&nbsp;</p> <p><strong>Q. What are the potential risks of SCR or are patients better off with a reverse TSA?</strong></p> <p><strong>A.</strong> The SCR does not burn any bridges and can be performed arthroscopically. The procedure carries minimal risk, as compared to a reverse total arthroplasty, which has increased risk of infection, failure, fracture, neurovascular complications and many more. Japanese surgeons have accepted the SCR technique as the reverse was just recently approved for use in Japan in July 2014.</p> <p><strong> <img alt="SCR" class="pull-right" src="" style="padding: 7px;" width="150" />Q. Can you comment on your own clinical experiences and patient results? </strong></p> <p><strong>A.</strong> We have refined this challenging procedure to make it simpler for the surgeon and less painful for the patient. My patients have been uniformly excited about their outcomes. Having had multiple failed attempts at rotator cuff repairs, they have all commented at how much easier the rehabilitation has been and how much less pain they have had. My results are consistent with Dr. Mihata&rsquo;s report.</p> <p><strong>Q. How do you perform the procedure? </strong></p> <p><strong>A.</strong> I use a 3.5 mm ArthroFlex dermal allograft. We measure the defect and cut the graft to size. Beach chair positioning is preferred as this allows the arm to be placed neutrally for fixation so as not to over tighten the graft. The graft is placed arthroscopically with a PASTA Bridge fixation medial to the labrum on the glenoid and a SpeedBridge laterally on the greater tuberosity. We retain the labrum for stability. We attach the graft to the infraspinatus to prevent escape of the head.&nbsp;The anterior margin of the graft is attached to the remaining rotator interval tissue; however, if no tissue exists, then the graft should not be over constrained by attaching to the subscapularis.</p> <p><strong>Q. Your experiences would suggest this is a promising&nbsp;technique. What are your thoughts looking forward?</strong></p> <p><strong>A.</strong> There are limited solutions between repair and arthroplasty&nbsp;for patients with irreparable massive rotator cuff tears without&nbsp;arthritis. I see this becoming the newest option in our&nbsp;bag to help the younger, nonarthritic active patients.</p> Danielle Batsios Arthrex Launches Virtual Surgery App – An Interactive Surgical Technique Learning System <p> <img alt="Virtual Surgery App" class="pull-right" src="" style="padding: 7px;" width="300" />The <a href=";mt=8" target="_blank" rel="nofollow noopener">Arthrex Virtual Surgery app</a> is a novel interactive surgical technique learning system that allows surgeons,&nbsp;OR staff and students to reinforce their knowledge, practice their decision-making skills and document their level of expertise of modern surgical procedures utilizing an iPad. Virtual surgery tests the user&rsquo;s ability to accurately identify the correct surgical instruments or implants used in sequence during an orthopaedic surgical procedure simulated in a 3D animated format.<br /><br />Intuitive touch screen navigation and interactive features makes the Virtual Surgery app easy to use.&nbsp;Once downloaded from the Apple app store and logged onto the app, users may select one of many surgical techniques from the extensive, up-to-date library of advanced orthopaedic surgical procedures on their iPad.<br /><br />Downloading exams is fast and provides easy access to 3D animations and exam questions, also available for offline use. After watching a brief 3D animation of the surgical procedure, users can take the corresponding exam on the correct instrumented steps of a specific surgical procedure.&nbsp;During the exam, a random set of instruments and implants appears at the bottom of each animated surgical step to challenge the user to make the correct choice.&nbsp;Visual cues provide immediate feedback about the user&rsquo;s choices and the amount of time required to complete the exam is also recorded. At the end of the exam, users are presented with an interactive summary screen of their results. Users may retake exams until proficiency is achieved. &nbsp;<br /><br /> <img alt="Virtual Surgery App" class="pull-left" src="" style="padding: 7px;" width="300" />A digital certificate of completion is awarded to the user after correctly answering all exam questions on a specific surgical technique. The certificate in PDF format can be emailed from the app to document the user&rsquo;s technology-based competency of the surgical procedure.<br /><br />Surgeons may challenge their OR staff, fellows, residents and students to achieve a high level of understanding of modern orthopaedic surgical techniques as they evolve, with new virtual surgery techniques emerging and added to the app library on a frequent basis, as new technology improves surgical techniques in the future. &nbsp;<br /><br />Gain immediate access to some of the most popular orthopaedic surgical procedures and streamline the way you educate yourself, as well as your entire staff, by <a href="" target="_blank" rel="nofollow noopener">downloading the new Arthrex Virtual Surgery app</a>. &nbsp; <br /><br />To learn more, view the <a href="" target="_blank" rel="nofollow noopener">Arthrex Virtual Surgery app tutorial</a>.<br /><br /><strong>Requirements:</strong> &nbsp; <br />-&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; login <br />-&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; iOS 7.0 or later: Instructions for updating your mobile device OS can be found at: <a href="" target="_blank" rel="nofollow noopener"></a>&nbsp;&nbsp; &nbsp; <br /><br /><strong>Support:</strong><br />-&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Arthrex Virtual Surgery App <a href="" target="_blank" rel="nofollow noopener">Support Homepage</a> <br />-&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Arthrex Virtual Surgery App Support Email: <a href=""></a>&nbsp;<br /><br /></p> Danielle Batsios New Flexible Arthroscopic Retractor by Bruce Levy, MD&nbsp; &nbsp;<br><br> <img alt="Dr. Levy" class="pull-left" src="" style="padding: 7px;" width="140" />Arthrex recently released the new Flexible Arthroscopy Retractor (FAR) for knee surgery. &nbsp; <br><br>I designed the FAR with Arthrex to allow better exposure at the base of the PCL facet for tibial tunnel/socket placement when performing PCL reconstruction or PCL avulsion repair. I found that exposure to this area was always difficult; not only to visualize the area but I also had fear of getting too close to the neuro-vascular bundle. We wanted to create something that could be inserted and removed easily and would help surgeons better see this tricky area. &nbsp; <br><br>The FAR is made from flexible, tear-resistant polyurethane. This is the same material used to protect the 2.4 guide pins and spade tip guide pins. After a series of trial and error with sizes and shapes, we found a reproducible device that met all the goals mentioned above. &nbsp;<br> <br> <img alt="FAR" class="pull-right" src="" style="padding: 7px;" width="225" />I was pretty excited the first time I tried the actual device. It was easy to insert and remove, gave me excellent exposure to the PCL facet, and the water pressure from the pump kept the FAR expanded, thus moving the posterior capsule away from the surgical field. Although not designed to protect neuro-vascular injury, I have to say it made me feel better having the FAR in place. &nbsp; <br><br>To place it, you simply pinch the tip with a snap and insert it into the knee either through a PM portal or any anterior portal. It is then manipulated to the back of the knee at the base of the PCL facet. To remove, simply pull on the suture and it will easily come out any portal. &nbsp; <br><span><br>I have found the FAR to be extremely instrumental for PCL surgery and hope other surgeons will find this advancement just as helpful.&nbsp;</span> Danielle Batsios What’s in my Bag? CMC TightRope for Revisions or Advanced Disease with John Safanda, MD <p> <img alt="CMC Mini TightRope" class="pull-right" src="" style="padding: 9px;" width="300" /><strong>Q: When do you use the TightRope?<br /></strong><strong><br /></strong>A:&nbsp; I personally use the TightRope for all of my CMC arthroplasties. It is also a great option for advanced disease or in revision cases where tendon options may not be available. &nbsp; <br /><strong><br />Q: How many patients have you performed this procedure on?&nbsp;What are your results?</strong><br /><br />&nbsp;A: We began using the TightRope in 2009 and have performed the procedure on more than 150 patients.&nbsp;We recently completed the analysis of our first 100 patients.&nbsp; We were able to maintain metacarpal height in all patients irrespective of their preoperative arthritic stage. We also showed a statistically significant improvement in thumb abduction postoperatively. <strong>&nbsp;</strong> <br /><strong><br />Q: How has your surgical technique changed or evolved during the last five years?</strong> <br /><br />A: The biggest change is that I quickly realized that I could place and secure the TightRope prior to excision of the trapezium. This allows us to precisely reconstruct the normal anatomy. &nbsp; <br /><strong><br />Q: What are the advantages of the TightRope in cases of advanced CMC arthritis?</strong> <br /><br />A:&nbsp;The TightRope affords improved suspension as compared with traditional LRTI because the axis of suspension is placed higher on the index metacarpal. This allows us to better restore the thumb metacarpal height. This is particularly helpful in revision cases with proximal migration or in cases of advanced arthritis. &nbsp; <br /><strong><br />Q: Are there additional advantages?</strong> <br /><br />A: Yes. By restoring the thumb metacarpal to its original height MP joint hyperextension is also improved.&nbsp;This has dramatically limited my need to perform stabilizing procedures or fusions at the MP joint. &nbsp; <br /><strong><br />Q: What is your post-op protocol in these cases?</strong> <br /><br />A: Because of the immediate stability the TightRope provides, I am able to place both my straightforward and complex/revision cases into an accelerated post-op protocol. Patients are splinted for one week following surgery.&nbsp;At one week the post-op splint is removed and physical therapy is initiated. In addition to motion exercises, we allow the patient to begin pinch and grip strength training on the first day of therapy.&nbsp;</p> Danielle Batsios Biomechanical and Clinical Results of ACL GraftLink? by Frank Cordasco, MD, MS, and Daniel Green, MD, MS, FAAP, FACS<br><br> <img alt="FrankCordasco" class="pull-left" src="" style="padding: 7px;" width="138" /> <img alt="DanielGreen" class="pull-left" src="" style="padding: 7px;" width="150" />Anterior cruciate ligament (ACL) injuries in skeletally immature athletes are increasing secondary to multiple factors that include increased participation and level of competition within sports, sports specialization and societal factors.&nbsp;Conservative treatment of these injuries has a poor natural history due to recurrent instability with meniscal and articular cartilage damage (1,2,3).&nbsp;<br><br>All Inside, all-epiphyseal ACL reconstruction in children appears to be a safe and effective treatment (2,5-9). The availability of pediatric guides provides surgeons an opportunity to apply All-Inside ACL reconstruction techniques just as they would in adults without significant risk to the physis (2,4,6). We have evaluated this technique in our biomechanics laboratory and have found the kinematic and contact stress properties to be favorable compared to the ACL deficient state and other ACL reconstruction procedures (5,8). One of the main advantages of this technique is that there is no fixation device distal to the proximal tibial physis or proximal to the distal femoral physis nor do the sockets cross the growth plate (2,3,4). In addition the GraftLink hamstring technique provides a graft that is often 9 to 11 mm in diameter, which is preferred as grafts less than 8.5 mm in diameter have been shown to have a higher failure rate.<br><br>Historically, the skeletally immature athlete with a complete ACL tear was either treated with benign neglect or some combination of extraarticular and intraarticular reconstruction (to avoid injury to the physis), often necessitating arthrotomy with the associated morbidity and local soft tissue trauma. These were often non-anatomic reconstructions that would not&nbsp;be performed in the adult population.<br><br>The all-epiphyseal ACL reconstruction is a modification of the original epiphyseal ACL reconstruction described by<span> Anderson (transepiphyseal ACL reconstruction) (2,3). The All-Inside, all-epiphyseal technique allows for a minimally invasive anatomic reconstruction using hamstring autograft. Our initial two-year follow up with this procedure demonstrates good functional results and physeal safety (6,7,9).<br><br></span> <img alt="Biomechanical GraftLink" class="pull-right" src="" style="padding: 7px;" width="250" />The “All-Inside”<span> technique creates epiphyseal sockets with a cortical bone bridge rather than tunnels with openings at both ends, which uses an “Outside-In” technique. We believe these sockets allow for improved biologic healing of soft tissue grafts to bone (10). The All-Inside technique has been performed in adults and based upon our experience with this procedure and instrumentation in the adult population, we developed this technique for use in the pediatric and young adolescent populations. We are performing ACL reconstructions in the skeletally immature athlete utilizing these principles, essentially performing an “adult type of reconstruction” in the skeletally immature - now with the ability to do so without compromising the physis.<br></span><br>Finally, this instrumentation allows for versatility in treating the young athlete with either an all-inside, partial transephyseal (Hybrid) or complete transphyseal reconstruction, based upon the athlete’s skeletal age and the potential for further growth in a safe and effective manner. &nbsp;<br><br>In our experience, an All-Inside, all-epiphyseal ACL reconstruction technique using hamstring autograft demonstrates excellent subjective and objective clinical outcomes in skeletally immature athletes without growth disturbance. There was a 4% graft failure rate and a 9% incidence of second surgery in this cohort (9). The ‘Return to Play’ assessment is an important tool to guide the young athlete and his or her family regarding resumption of competitive sports. Young athletes were on average released for full return to sport after one year from ACL reconstruction (9).<span>&nbsp;<br></span><br><br><strong>References:</strong> &nbsp; <br>1. Cordasco FA. CORR Insights? on meniscal injury after adolescent anterior cruciate ligament injury: how long are patients at risk? <em>Clin Orthop Relat Res</em>.&nbsp;2014; 472(3):998-1000. &nbsp;<br><br>2. McCarthy MM, Graziano J, Green DW, Cordasco FA. All-epiphyseal, all-inside anterior cruciate ligament reconstruction technique for skeletally immature patients. <em>Arthrosc Tech</em>. 2012;1(2):e231-e239. &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <br><br>3. Fabricant PD, Jones KJ, Delos D, Cordasco FA, et al. Reconstruction of the anterior cruciate ligament in the skeletally immature athlete: a review of current concepts: AAOS exhibit selection [erratum, <em>J Bone Joint Surg Am</em>. 2013;95(16):e117].<em> J Bone Joint Surg</em>. 2013;95(5):e28. &nbsp; <br><br>4. Fabricant PD, McCarthy MM, Cordasco FA, Green DW. All-inside, all-epiphyseal autograft reconstruction of the anterior cruciate ligament in the skeletally immature athlete: a surgical technique. <em>JBJS Essent Surg Tec. </em>2013;3(2):e9. &nbsp; <br><br>5. McCarthy MM, Tucker S, Nguyen J, Green DW, Imhauser CW, Cordasco FA. Contact stress and kinematic analysis of all-epiphyseal and over-the-top pediatric reconstruction techniques for the anterior cruciate ligament<em>. Am J Sports Med</em>. 2013. 41(6):1330-1339. &nbsp; <br><br>6. Nawabi DH, Jones KJ, Lurie B, Potter HG, Green DW, Cordasco FA. All-inside, physeal-sparing anterior cruciate ligament reconstruction does not significantly compromise the physis in skeletally immature athletes: a postoperative physeal magnetic resonance imaging analysis.&nbsp;<em>Am J Sports Med.</em>&nbsp;2014. pii: 0363546514552994. &nbsp; <br><br>7. Nawabi D, McCarthy M, Graziano J, et al. Return to play and clinical outcomes after all-inside, anterior cruciate ligament reconstruction in skeletally immature athletes. Paper presented at: 2014 Annual Meeting of the American Orthopaedic Society for Sports Medicine; July 10-13, 2014; Seattle, WA. &nbsp; <br><br>8. McCarthy MM, Imhauser C, Fabricant P, Green DW, Cordasco FA. Kinematics and contact stress comparison of all-epiphyseal and complete transphyseal reconstructions. Presenting at: 2014 Specialty Day of the American Orthopaedic Society for Sports Medicine; March 28, 2015; Las Vegas, NV. &nbsp; <br><br>9. Cordasco FA, Graziano J, DeMille P, et al.<strong> </strong>All-inside, all-epiphyseal ACL reconstruction in skeletally immature athletes: return to play, incidence of second surgery and two-year clinical outcomes. Presenting at AANA 2015.<strong></strong> &nbsp; <br><br>10. Smith P, Cook JL, Stannard J, Pfeiffer F, Kuroki K. Suspensory versus interference screw fixation for arthroscopic ACL reconstruction in a novel canine model. 2014 ACL Study group meeting; February 4, 2014; Cape Town, South Africa. &nbsp; <br><em><span><br>Frank Cordasco, MD, MS, and Daniel Green, MD, MS,&nbsp;</span></em><em>FAAP, FACS,</em>&nbsp;<em>are surgeons at Hospital for Special Surgery and are consultants to Arthrex Inc.</em><br><br> Danielle Batsios Top 12 Orthopaedic Videos at Arthrex in 2014 <img alt="Whatsnew" class="pull-left" src="" style="padding: 0px;" width="600" /><br><br><br><br><br><br><br><br><br>For the past two years, Arthrex has helped you stay focused on emerging orthopaedic technology by providing you exclusive access to exciting new orthopaedic surgical techniques, presentations, animations and surgeon-authored blogs in our weekly <em>What's New at Arthrex</em> email newsletter. This year, we expanded our newsletter family from sports medicine and arthroscopy to include <em>What’s New</em> emails specifically focused on content in the areas of arthroplasty, hand and wrist surgery and foot and ankle surgery.<br><br><strong>Our second annual anniversary editions of our "What's New" newsletters will highlight the top 12 features in our newsletter&nbsp;over the past year.</strong> It will include our most popular surgical technique videos, presentations, demonstrations and blogs by leading orthopaedic surgeons from around the world. This information is based on the amount of visits these assets obtained throughout the year by your peers.<strong> </strong><a target="_blank" rel="nofollow" href=""><strong>Get your copy by subscribing here</strong></a>.&nbsp;<br><br><strong>You can now also get our DAILY innovations several new ways</strong>! Visit the <a target="_blank" rel="nofollow" href="">front page of</a> or follow us on Twitter - <a target="_blank" rel="nofollow" href="">@ArthrexWhatsNew</a>.<br><br>Stay tuned in 2015 for even more exciting technology from Arthrex, continuing our mission of helping surgeons treat their patients better through innovation!<br> Cassandra Engeldinger Quad Tendon Q&A with John Xerogeanes, MD <p> <img alt="Dr. Xerogeanes" class="pull-left" src="" style="padding: 7px;" width="125" /><strong>Why should I consider using a quadriceps tendon graft? <br /></strong> The quad tendon is an excellent ACL graft source and an equal and in some areas superior alternative to both the hamstring and patella tendon grafts. &nbsp; <br /><strong><br />Is the QT graft stronger than the bone-patella tendon-bone (BPTB) graft?</strong> <br />The ultimate load of a 10 mm wide QT is almost 30% higher than a 10 mm wide BPTB. Also, while it is significantly stronger, the modulus (how the tissue acts) is significantly closer to that of the native ACL.<em>* data on file</em>&nbsp;&nbsp; <br /><strong><br />How does the QT compare histologically to the BPTB graft? <br /></strong> QT had 20% more collagen per cross sectional area than the BPTB. &nbsp;<br /><br /><strong>Do you see QT ruptures after harvesting a QT graft?&nbsp; <br /></strong> No. The intact quad tendon is significantly larger than the intact patella tendon. Interestingly, after the harvest of a typical 10 mm wide QT graft, the remaining quadriceps tendon is 20% stronger than the intact patella tendon. &nbsp; <br /><strong><br />What are the other advantages of the all-soft tissue QT graft over B-PT-B graft?&nbsp; <br /></strong> The graft is stronger, has superior histology, is almost twice as thick as the PT and thus, produces a graft with 88% more intraarticular volume than an equal width BPTB graft, can be utilized on every age and size patient, produces no anterior knee numbness, and had minimal incidence of post operative frontal knee pain, is faster to harvest and is cosmetically superior.<em>* data on file</em><br /><br /><strong>What are the advantages of a QT graft over a hamstring graft?</strong> <img alt="quad tendon" class="pull-right" src="" style="padding: 7px;" width="250" /> &nbsp;<strong>&nbsp; <br /></strong> The biggest advantage is that its size (length and girth) are easily predicted using a simple preoperative measurement on a standard MRI, thus avoiding the small, short graft. There is also no permanent muscle weakness or anterior leg numbness which is often seen when utilizing the hamstring graft. &nbsp; <br /><strong><br />How does the harvest time compare to the other grafts?</strong> <br />It takes less than 10 minutes to harvest the QT graft and close the wound. This is compared to 25 minutes for the patella tendon graft and 15 minutes for the hamstring.<br /><br /><strong>Is graft size easily predictable?</strong> <br />Yes, unlike a hamstring graft, the QT&rsquo;s cross sectional area can be easily determined by looking at a standard sagittal cut on the preoperative MRI. &nbsp; <br /><strong><br />Is the length of the potential graft predictable? &nbsp;&nbsp;</strong> <br />The length of the potential graft was determined through MRI studies and correlated to the height of the patient. In patients over 5 feet tall, 90% of patients have potential graft lengths of over 7 cm. This value can be increased by 2 cm in every patient by harvesting into the myotendinous area of the rectus femoris. &nbsp;<br /><strong><br />Is the graft suitable for all sizes and ages of people?</strong><br />Yes, because it is an all-soft tissue graft it can be used in patients of all ages. Also, unlike hamstring grafts the cross sectional area and length is sufficient to allow a graft greater than 7 mm diameter in patients older than 7 years old.<br /><br /><strong>Do you have to have a more conservative postoperative treatment plan compared to a BPTB graft?</strong> <br />No, a standard accelerated ACL rehabilitation plan can be utilized (;In fact, since frontal knee pain is not a concern, we can actually be more aggressive in quad strengthening compared to a BPTB graft. &nbsp; <br /><strong><br />How long does the graft need to be? <br /></strong> The average length of the ACL is 2.5 to 3 cm. Most surgeons want 2 cm of graft in each tunnel, thus 7 cm is the perfect length. <strong>&nbsp;<br /></strong> <strong><br />Is soft tissue graft fixation sufficient?</strong> <br />Yes, there are long-term outcomes published by both Shelton and Fulkerson showing that suture suspensory fixation of the soft tissue graft leads to excellent outcomes. My short-term outcomes, 0-3 years and nearly 300 grafts have equal outcomes to both BPTB and HS grafts, with no significant changes in KT values from six weeks to six months. &nbsp; <br /><strong><br />Is QT graft suitable for a revision surgery?</strong>&nbsp; <br />Secondary to its cross sectional area and its strength, it is an excellent graft for revision surgery. It is easy to harvest graft diameters equal to or greater than 11 mm. This is especially true if the previous tunnels were placed properly and a larger diameter graft is needed.<br /><br /><strong>If a surgeon is considering using a QT graft, what steps should he take to prepare himself?</strong> <br />I would recommend first familiarizing oneself with the anatomy. Our article in the October 2013 issue of <em>AJSM</em> (<a href="" target="_blank" rel="nofollow noopener">Xerogeanes et al</a>) is a good resource. Second, start looking at your MRIs. Measure the thickness of the quad tendon on the mid sagittal cut of the MRI and compare it to the thickness of the PT on the same cut. Thirdly, familiarize yourself with the TightRope&reg; RT and the FiberLoop&reg;. Next, try passing your graft through the AM auxillary portal. Lastly, view the technique video the <a href="" target="_blank" rel="nofollow noopener">Minimally Invasive Quad Tendon Harvest for ACL Reconstruction technique video</a>. &nbsp; <br /><strong><br />Are there long-term outcomes?</strong>&nbsp; <br />Yes, there are multiple studies referenced in the<a href=";Expires=1546875008&amp;Signature=pO2tXwwpF90jsL4AB5NanBCM%2FbY%3D" target="_blank" rel="nofollow noopener"> Minimally Invasive Quad Tendon Harvest System Surgical Technique Guide</a> showing that the quadriceps tendon both with or without a bone plug have long-term outcomes equal to that of both the patella and hamstring tendons. Shelton, Geib, Fulkerson and Staubli are just some of the authors who have published these studies. &nbsp; <br /><strong><br />Are the harvest instruments essential to harvesting the tendon?</strong> <br />Yes, these instruments were designed specifically to make harvest of the QT reproducible, safe and easy. Also, they are essential to allow usage of a small cosmetic incision.<br /><strong><br />What are the specific advantages of the harvest instruments?</strong> <br />The graft knife comes in sizes that will allow different widths for the surgeon to customize the size of the graft. The most commonly used size is the 10 mm width. This blade also is set with a depth stop and a 7 mm deep blade so the surgeon can avoid violating the joint capsule if he chooses to use a partial thickness graft. It also has length measurements so the surgeon can accurately control the length of the cut. The Graft Cutter can perform two functions. It can strip the graft free of proximal soft tissue attachments and then transect the graft at a specific length. This enables time efficiency and the need for multiple or large graft harvest incisions.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; <br /><strong><br />Are there any complications unique to the quad tendon graft?</strong> <br />The unique complications are seen when a graft is greater than8 cm in length is harvested. During these harvests, the rectus femoris is violated. The complications that can be seen are bleeding in the thigh. Thus, all patients&rsquo; thighs are palpated in the recovery room prior to discharge to make sure they are not tense. The other complication is cosmetic with a retraction of the rectus femoris muscle. This does not affect the patient&rsquo;s strength. Again, these complications are extremely rare and only seen with proximal harvests. &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <br /><strong><br />Do you like an All-Inside&reg; technique?</strong> <br />Yes, the All-Inside technique basically changes two things done historically; Pass the graft through the AM auxillary portal and drill sockets instead of complete tunnels. This dramatically changes the ease of graft passage and saves native bone stock. It also decreases surgical time. &nbsp; <br /><strong><br />If you want to drill traditionally, are there any parts of the All-Inside&reg; technique you would still recommend?</strong> <br />Yes, I would still recommend passing the graft through the aux AM portal into the femur, then retrograde through the tibia. This will allow you to avoid the sharp turns when performing an anatomic ACL preservation.<br /><br /><br /><strong>References:</strong><br />Xerogeanes JW, Mitchell PM, Karasev PA, Kolesov IA, Romine SE. Anatomic and morphological evaluation of the quadriceps tendon using 3-dimensional magnetic resonance imaging reconstruction: applications for anterior cruciate ligament autograft choice and procurement. <em>Am J Sports Med</em>. 2013 Oct;41(10):2392-9. doi: 10.1177/0363546513496626. Epub 2013 July 26.<br /><br />DeAngelis JP, Fulkerson JP. Quadriceps tendon: a reliable alternative for reconstruction of the anterior cruciate ligament. <em>Clin Sports Med</em>, 2007;26(4):587-596.<br /><br />Fulkerson JP. Central quadriceps free tendon for anterior cruciate ligament reconstruction. <em>Oper Tech Sports Med</em>. 1999;7:195-200.<br /><br />Geib TM, Shelton WR, Phelps RA, Clark L, Anterior cruciate ligament reconstruction using quadriceps tendon autograft: intermediate-termoutcome. <em>Arthroscopy</em>. 2009;25(12): 1408-1414.<br /><br />Harris NL, Smith DA, Lamoreaux L, Purnell M, Central quadriceps tendon for anterior cruciate ligament reconstruction, part I: morphometric and biomechanical evaluation<em>. </em> <em>Am J Sports Med</em>. 1997; 25(1):23-28.<br /><br />Lippe J, Armstrong A, Fulkerson JP, Anatomic guidelines for harvesting a quadriceps free tendon autograft for anterior cruciate ligament reconstruction<em>.</em> <em>Arthroscopy</em>. 2012;28(7): 980-984.<br /><br />Staubli HU, Bollmann C, Kreutz R, Becker W, Rauschning W, Quantification of intact quadriceps tendon, quadriceps tendon insertion, and suprapatellar fat pad: MR arthrography, anatomy, and cryosections in the sagittal plane<em>.</em> <em>AJR Am J</em> <em>Roentgenol</em>. 1999;173(3):691-698.<br /><br />Staubli HU, Schatzmann L, Brunner P, Rincon L, Nolte LP, Quadriceps tendon and patellar ligament: cryosectional anatomy and structural properties in young adults. <em>Knee Surg Sports Traumatol Arthrosc</em>. 1996;4:100-110.</p> Danielle Batsios What's In My Bag? 3.5 mm SwiveLock with Steven Lee, MD <p> <img alt="Lee" class="pull-left" src="" style="padding: 7px;" width="150" /><strong>Q. What made you start using the SwiveLock anchor for scapholunate&nbsp;</strong><strong>dissociations?</strong><br /><br /><strong>A.</strong> Currently, treatments of scapholunate dissociations are suboptimal and often unsatisfactory. Direct repairs are rarely successful and typically&nbsp;fall apart so we rely on a secondary procedure like a capsulodesis to help control DISI deformity. Therefore, a reconstruction makes more&nbsp;sense. However, current reconstructions are either too complex to perform or have weak fixation strength. SwiveLocks are easy to use&nbsp;and have unbelievably strong fixation strength, allowing the tendon to&nbsp;heal into the bone as opposed to the surface of the bone.<br /><br /><strong>Q</strong>. <strong>Can you describe your operating technique when using these SwiveLocks?</strong><br /><strong><br /></strong> <img alt="SwiveLock" class="pull-right" src="" style="padding: 7px;" width="250" /><strong>A.</strong> The operative technique entails using a tendon graft to reconstruct the dorsal portion of the scapholunate interosseous ligament as well as to control the relationship of the lunate to the distal pole of the scaphoid. After restoring the DISI deformity to normal alignment using K-wires, the tendon graft along with a 2-0 FiberLoop is dunked into the proximal pole of the scaphoid with a modified 3.5 mm PEEK SwiveLock. Both the tendon graft and the FiberLoop are dunked into the lunate and secured with another 3.5 mm SwiveLock. Then the graft and FiberLoop is dunked into the distal pole of the scaphoid with a third SwiveLock. The tendon graft is reinforced with the double-stranded 2-0 FiberLoop as an internal brace to provide extra fixation strength during the time that the tendon graft is healing into the bone. I have&nbsp;been leaving the K-wires in for added provisional fixation, and taking&nbsp;them out at about six weeks.<br /><br /><strong>Q.</strong> <strong>What are a few of the significant advantages over current techniques&nbsp;</strong><strong>you have tried?</strong><br /><br /><strong>A.</strong> The advantages of this technique are that it does not rely on the healing of the native ligament which in my mind usually does not heal after a direct repair (sort of like an ACL). Therefore, it can be used acutely or chronically as long as significant arthritis hasn&rsquo;t set in and the carpal bones are still reducible. This reconstruction&nbsp;addresses not only SLIL, but also the flexion of the scaphoid and the&nbsp;extension of the lunate. Finally, it&rsquo;s relatively easy and fast to do. Typically&nbsp;this surgery takes about 30-45 minutes to perform.<br /><br /><strong>Q.</strong> <strong>What is your post-op protocol?</strong><br /><br /><strong>A.</strong> I put the patient into a plaster thumb spica splint immediately post-op, then change them over to an orthoplasty type thumb spica splint, which&nbsp;stays on until about six weeks post-op. I take out the K-wires and start on&nbsp;a hand therapy program that typically goes for about six weeks.</p> <p>&nbsp;</p> <p><em>The views expressed in this post reflect the experience and opinions of the presenting surgeon and do not necessarily reflect those of Arthrex Inc.</em></p> Danielle Batsios New Scientific Article Published on GraftLink ACL Reconstruction <img alt="GraftLink" class="pull-right" src="" style="padding: 7px;" width="250" /><span>A recent study&nbsp;published in the <em>Journal of Knee Surgery&nbsp;</em></span>authored by surgeons at the Mayo Clinic describes the latest advances in All-Inside ACL Reconstruction&nbsp;and describes their preferred GraftLink technique and surgical outcomes.&nbsp;According to the authors, the GraftLink technique may provide advantages of gracilis preservation, less bone removal, less post-operative pain and improved cosmesis. Clinical data on 95 patients at a minimum of six months (mean 22.4 months, range 7.8-35.3 months) showed knee&nbsp;stability measures, knee strength and complication rates in line with standard techniques. &nbsp;<br><a target="_blank" rel="nofollow" href="">Read more &gt;&gt;</a><br><br>Article reference:<br><span><a target="_blank" rel="nofollow" href="">Blackman AJ, Stuart MJ. All-inside anterior cruciate ligament reconstruction. </a><em><a target="_blank" rel="nofollow" href="">J Knee Surg</a></em><a target="_blank" rel="nofollow" href="">. 2014; 27(05): 347-352.</a></span> Danielle Batsios What's In My Bag? CMC TightRope with Jeffrey Yao, MD <img alt="Dr. Yao" class="pull-left" src="" style="padding: 7px;" width="125" /><strong>Q. How long have you been using the Mini TightRope for CMC arthritis?</strong>&nbsp;<br><br><strong>A.</strong> Six years&nbsp;<br><br><strong>Q. What are the overall benefits of using the TightRope versus a more&nbsp;traditional ligament reconstruction tendon interposition (LRTI) or&nbsp;hematoma distraction arthroplasty?<br></strong><br><strong>A.</strong> By using the TightRope, I don’t have to wait for soft tissue reconstruction&nbsp;to heal (LRTI, APL suspensionplasty) and I also don’t have to leave&nbsp;any external K-wires to maintain the trapeziectomy space (hematoma&nbsp;distraction arthroplasty). Therefore, I can initiate a rehabilitation&nbsp;protocol as early as 5–7 days after surgery with this implanted&nbsp;device, maintaining my trapeziectomy space. <img alt="CMC Mini TightRope" class="pull-right" src="" style="padding: 7px;" width="250" /><strong>&nbsp;</strong><br><br><strong>Q. What type of patient is the TightRope indicated for?</strong><strong><br></strong><br><strong>A.</strong> Any patient with thumb carpometacarpal joint arthritis that fails&nbsp;nonsurgical treatment measures (such as splints, injections, activity&nbsp;modifications and therapy).<br><br><strong>Q. How has this changed your post-op protocol?&nbsp;<br></strong><br><strong>A.</strong> This device has been a game changer for me because instead of&nbsp;immobilizing my patients for four weeks (with or without an external&nbsp;K-wire), I am able to accelerate the post-op protocol by starting it&nbsp;5–7 days following surgery. I don’t start therapy immediately because&nbsp;I do believe a week is appropriate to allow the skin and other soft&nbsp;tissues to heal, but I suppose immediate therapy would be ok as well&nbsp;with this technique.<br><br><strong>Q. How many patients have you performed this procedure on?<br></strong><br><strong>A.</strong> Over 50. <br><br><strong>Q. How have your patients responded to the CMC Mini TightRope in&nbsp;contrast to previous technique options?&nbsp;</strong><br><br><strong>A.</strong> The overall recovery is much faster with this technique. Typical full&nbsp;recovery is around three months as compared to 3–6 months or more&nbsp;for my previously-preferred techniques (arthroscopic hemitrapeziectomy&nbsp;and pinning for four weeks or APL suspensionplasty). It has been most&nbsp;telling in my patients who had one of those previous procedures on&nbsp;one thumb and then had the TightRope suspensionplasty on the second&nbsp;thumb and they have been universally happier with the TightRope&nbsp;procedure because of the decreased recovery time. Danielle Batsios What's In My Bag? Compression FT Screws with Steven Shin, MD <p> <img alt="Dr. Steven Shin" class="pull-left" src="" style="padding: 7px;" width="150" /><strong>Q. What made you decide to use headless screws over a four-corner&nbsp;fusion plate for a four-corner fusion?</strong>&nbsp;<br /><strong>A.</strong> I used different four-corner fusion plates for several years and was never&nbsp;completely satisfied with the results, especially with the nonunions. I also&nbsp;did not like the large amount of dorsal reaming required to make the&nbsp;concave recess necessary for placement of the plate. With the excellent&nbsp;compression provided by Headless Compression Screws, their ease&nbsp;of placement and their completely buried locations within the carpal&nbsp;bones, I quickly made the transition to using them for intercarpal fusions,&nbsp;including four-corner fusions. I have been very pleased with the results.&nbsp;Nonunions have become very rare in my experience with these screws&nbsp;and even when they do occur, they are often times not painful due to the&nbsp;rigid fixation provided by the screws.<br /><br /><strong>Q. What is your preferred placement for these screws?&nbsp;</strong><br /><strong>A.</strong> For four-corner fusions, my preferred placement is as follows: one&nbsp;retrograde 3.5 mm screw across the capitolunate joint (with a starting&nbsp;point at the dorsal base of the third metacarpal), one ulnar-volar to&nbsp;radial-dorsal 3.5 screw across the lunotriquetral joint and one ulnar-dorsal&nbsp;to radial-volar 3.5 mm screw across the triquetrum-hamate-capitate&nbsp;joints. An alternative construct is using four screws, one for each of the&nbsp;intercarpal joints, but I&rsquo;ve found that three screws do just as well.<br /><br /> <img alt="screws" class="pull-right" src="" style="padding: 7px;" width="300" /><strong>Q. Are there any advantages with the new Compression FT Screws over&nbsp;screws that you were previously using?</strong><br /><strong>A.</strong> The Compression FT Screws provide excellent compression and&nbsp;fixation, similar to other Headless Compression Screws that I was using&nbsp;before. One advantage I saw immediately when using the screw for&nbsp;the first time was that the guidewire did not become stuck and routinely&nbsp;come out with the cannulated drill bit after drilling. This saves time and&nbsp;money. I did not have to fiddle with trying to find the drill hole with a&nbsp;new guidewire and I did not have to ask for a new drill bit for the next&nbsp;screw. Another advantage is the star-drive design of the screw head,&nbsp;which allows for increased torque with the screwdriver and less risk of&nbsp;stripping. The straight outer diameter, or nonconical shape of the screw,&nbsp;is another advantage. If you end up undersizing or oversizing the length&nbsp;of the screw, you can insert the same diameter screw with a different&nbsp;length and still get excellent compression and fixation. The straight&nbsp;diameter drill bit means that you&rsquo;re not obligated to leave the screw in&nbsp;or go to a larger diameter screw.<br /><br /><strong>Q. What is your post-op protocol for this case?</strong><br /><strong>A.</strong> Due to the excellent compression and fixation with these screws, I&nbsp;allow gentle active range of motion (ROM) (no passive) after the first&nbsp;postoperative visit (7-10 days after surgery). I give the patient a wrist&nbsp;orthosis they can remove for bathing and exercises. I allow passive&nbsp;ROM and strengthening once I see evidence of bony union on&nbsp;radiographs or CT scan, around 6-8 weeks postoperatively.<br /><br /><strong>Q. What are some other indications for which you would use Headless&nbsp;Compression Screws?&nbsp;</strong><br /><strong>A.</strong> I use Headless Compression Screws for a number of other indications&nbsp;in the hand and wrist, including scaphoid fractures, radial styloid&nbsp;fractures, large ulnar styloid fractures (with DRUJ instability), other&nbsp;intercarpal fusions, and thumb and finger fusions. Specifically with&nbsp;the Compression FT Screws, I&rsquo;ve used them across the scapholunate&nbsp;(SL) joint for chronic SL ligament tears (without arthrosis) and lunate&nbsp;dislocations (one across the SL joint and one across the LT joint).</p> <p>&nbsp;</p> <p><em>The views expressed in this post reflect the experience and opinions of the presenting surgeon and do not necessarily reflect those of Arthrex Inc.</em></p> Kristin Bartlett Case Review: Lisfranc ORIF vs Primary Arthrodesis <strong><em>With Dr. Anand Vora<br><br></em></strong> <img alt="Dr. Vora" class="pull-left" src="" style="padding: 7px;" width="150" /><strong><em>Treatment Considerations for Acute Midfoot Lisfranc Injuries: Bridge Plating and Primary&nbsp;</em></strong><span><strong><em>Arthrodesis Techniques</em></strong><br><br>Current treatment considerations for acute traumatic lisfranc injuries&nbsp;require individualized assessment of the “personality” of the injury&nbsp;pattern. Recognition of the bony versus soft tissue component of the injury&nbsp;allows the ability to plan appropriate surgical intervention. Below are&nbsp;two cases with significantly different “personalities” treated with distinctly&nbsp;<span>different implant strategies.<br></span></span><span><strong><br>Case 1</strong><br><br>Traditional open reduction and internal fixation techniques require absolute&nbsp;anatomic reduction of the tarsal metatarsal articulations. Current techniques&nbsp;place heightened focus on use of implant constructs that minimize injury to&nbsp;the respective articular services to maintain fixation. Bridge plate fixation&nbsp;is an elegant method of fixation of bony and soft tissue components in&nbsp;Lisfranc injuries. The lack of intra-articular violation limits further iatrogenic&nbsp;development of midfoot arthrosis.<br><br>Case 1 demonstrates a 47-year-old female status post motor vehicle&nbsp;accident with acute ligamentous and bony Lisfranc injury. The frequent&nbsp;bony component of communition of the second metatarsal base requiring&nbsp;spanning fixation is present in this case. The Arthrex complete foot plating&nbsp;system is comprised of anatomically-specific plates that are ideal for such&nbsp;indications. The cloverleaf screw cluster in the proximal end of the plates&nbsp;allows for maximal fixation in the respective cuneiform and the distal plate&nbsp;extension allows the ability to reduce and bypass the zone of communition&nbsp;of the second metatarsal base fracture. The anatomic plates demonstrated&nbsp;spanning the first and third tarsometatarsal joints provide rigid fixation,while eliminating iatrogenic joint penetration. The plate construct is generally&nbsp;removed at 3 – 4 months status post injury. At the time of hardware removal&nbsp;a Mini TightRope is often placed from the healed base of the second&nbsp;<span>metatarsal to medial cuneiform to prevent late diastasis.<br><br></span></span> <img alt="Lisfranc" class="pull-right" src="" style="padding: 5px;" width="300" /><span><strong>Case 2</strong><br><br>For primarily soft tissue Lisfranc injuries, particularly when high energy,open reduction internal fixation techniques may be suboptimal and in such&nbsp;scenarios primary arthrodesis may offer a more appropriate solution.<br><br></span>Case 2 demonstrates a 64-year-old male status motorcycle accident with&nbsp;mainly ligamentous injury pattern with marked anatomical displacement.&nbsp;As with ORIF techniques, anatomic realignment of the tarsal metatarsal&nbsp;relationships is critical. Cartilage removal and joint preparation with&nbsp;fixation constructs optimizing compression allow for improved likelihood of&nbsp;union. The Arthrex Double Compression Plate construct has biomechanically&nbsp;demonstrated improved compression ability as compared to alternative&nbsp;compression staple plate devices. Optional locking and nonlocking fixation&nbsp;on one side of the planned arthrodesis site allows versatility in fixation&nbsp;options. On the other side of the arthrodesis site, the compression initially&nbsp;is obtained by traditional compression plating principles. This compression&nbsp;is further maximized via the staple arms of the plate for maximal compression&nbsp;fixation. The multiple geometric plate constructs and lengths allow for&nbsp;optimization of fixation for multiple anatomic areas of the foot and ankle&nbsp;including the transverse tarsal joints as demonstrated in this case example&nbsp;of primary arthrodesis of the first, second, and third tarsometatarsal joints. Kristin Bartlett Arthrex Ankle Fracture System with Troy Watson, MD <span> <img alt="Dr. Troy Watson" class="pull-left" src="" style="padding: 7px;" width="150" /><strong>Q. What type of fracture pattern/injury did your patient have?<br></strong></span><br>A. My patient highlighted this month is a Welterweight UFC fighter&nbsp;who sustained a severe fracture while competing in the octagon. He&nbsp;sustained a closed high ankle fracture with a syndesmosis rupture. He&nbsp;was taken to the operating room for urgent open reduction and internal&nbsp;fixation. At the onset, it was our goal to get him back into the ring as&nbsp;quickly as possible and return him to his pre-injury level of competition.<br><br><strong>Q. Considering you were treating a high-impact athlete, what type of&nbsp;implant were you looking for and why did you choose Arthrex?</strong><br><br>A. We were looking to provide stable internal fixation. We used the&nbsp;Arthrex one-third tublar plate and the TightRope device to stabilize&nbsp;the syndesmosis.<br><br><strong>Q. Was there anything unexpected during the case and did you have&nbsp;the implant and instrument selection you needed?</strong><br><br>A. I felt it was imperative to have multiple implant options during the case,&nbsp;should there be anything unexpected and that is exactly why I chose&nbsp;the Arthrex system. The set includes basic plates like one-third tubular&nbsp;plates and straight plates but also distal fibular anatomic plates as well&nbsp;as medial and lateral hook plate options. The screw selection is&nbsp;extremely comprehensive as well with everything from a 2.7 mm locking&nbsp;to 4.0 mm cannulated screws.&nbsp;Not only do I have a vast implant selection but the set has all the&nbsp;instruments I could need including Lobster Claws, pointed Reduction&nbsp;Forceps, dental picks and even a new syndesmosis clamp giving me&nbsp;full confidence I have all the tools necessary for a great case.&nbsp;I also will typically have BioCartilage in the room available in case we&nbsp;note a large osteochondral defect. In the high-impact athlete, I now&nbsp;perform an arthroscopy on these severe ankle fractures to evaluate the&nbsp;syndesmosis, as well as examine for chondral injuries.<br><br> <img alt="AnkleFractureSystem" class="pull-right" src="" style="padding: 7px;" width="300" /><strong>Q. What is your response to those who might be concerned about using&nbsp;the TightRope on an elite or high-impact athlete?</strong><br><br>A. There is increasing evidence and confidence with treating these athletes&nbsp;with a TightRope rather than screw fixation. In fact, many players with&nbsp;similar injuries in the NFL have returned to play with a TightRope in&nbsp;place. Placement of the TightRope at the time of the initial procedure&nbsp;obviates the need for an additional hardware removal procedure and&nbsp;may return the athlete to his sport more quickly. For those surgeons who&nbsp;remain skeptical, placement of one screw with a TightRope may offer a&nbsp;compromise with screw removal around week eight.<br><br><strong>Q. The Arthrex Ankle Fracture System has only been available since 2010. Was there a learning curve in dealing with a new system for&nbsp;you or your operating room staff?</strong><br><br>A. There really is no learning curve other than familiarizing yourself with&nbsp;the tray and the various plate constructs and instruments. Everything is&nbsp;color-coded in the set, making it very easy and straightforward for my&nbsp;operating room staff.<br><br><strong>Q. What is your postoperative protocol after using the TightRope&nbsp;with an associated ankle fracture?</strong><br><br>A. The ankle fracture typically dictates the post-op protocol here. In this&nbsp;case, we treated him initially with a splint and then advanced him&nbsp;to a cast for a few weeks. Following this, he was placed into a CAMboot at the four week mark and allowed to begin active range-of-motion&nbsp;exercises. He was advanced to full weight-bearing at six weeks out&nbsp;from surgery and started formal physical therapy at that time. He was&nbsp;placed into an ankle brace and shoe at ten weeks from surgery and&nbsp;continued to advance his activity in physical therapy. He returned to&nbsp;<span>training four months after surgery with a full release.<br></span> Kristin Bartlett What's In My Bag? Midsubstance Achilles SpeedBridge with James McWilliam, MD <img alt="Dr. McWilliam" class="pull-left" src="" style="padding: 7px;" width="125" /><strong>Q. Why do you prefer the percutaneous approach to Achilles&nbsp;</strong><strong>tendon repair?<br><br>A. </strong>Percutaneous Achilles repair enhances outcomes in two ways. Firstly, percutaneous repair is associated with a lower complication rate. Secondly, I firmly believe that, by less violation of the soft tissue&nbsp;envelope, a percutaneous repair leads to a better organized, stronger&nbsp;<span>tendon and quicker healing.<br><br><strong>Q. Is a percutaneous repair strong enough to allow for early&nbsp;</strong><strong>weight-bearing and mobility?</strong><br></span><br><strong>A. </strong>Numerous bench studies have shown superiority of percutaneous repair&nbsp;when compared to Krackow technique in terms of strength-to-failure and&nbsp;tendon lengthening prior to failure. Our own clinical study demonstrated&nbsp;no failures of repair two years after percutaneous technique even with&nbsp;<span>immediate weight-bearing and an accelerated rehabilitation program.*<br><br><strong>Q. Describe the evolution of your approach to percutaneous Achilles&nbsp;</strong><strong>tendon repair.<br></strong><br><strong>A.</strong> I was trained to do an open repair and was usually satisfied with the&nbsp;results. Occasionally, however, I would encounter wound complications&nbsp;and/or pain and disability due to tendon adhesions and chronic&nbsp;swelling. I began percutaneous repair using a modification of the&nbsp;Kakiuchi technique, retrieving the sutures in an intrasynovial fashion&nbsp;using a crochet hook. I immediately noticed an improvement in patient&nbsp;<span>satisfaction with regards to pain and return to activity.<br><br></span></span> <img alt="PARS" class="pull-right" src="" style="padding: 7px;" width="360" /><span>With the release of the Arthrex PARS system, locked sutures are possible, a feature that I feel enhances repair strength and prevents suture creep&nbsp;<span>and subsequent tendon lengthening.<br><br>Lately, I have been using a knotless PARS technique, with traditional&nbsp;percutaneous suture passage proximally with anchoring of the sutures&nbsp;into the heel (through the distal Achilles stump) directly into the calcaneus.&nbsp;This technique further minimizes soft tissue dissection and enhances&nbsp;repair strength. In addition, local irritation from bulky suture knots is<span>obviated.<br></span><br><strong>Q. What are the benefits of the Arthrex PARS system?<br><br>A. </strong>Economical, ergonomic, anatomic and&nbsp;efficient:<strong><br></strong></span></span><ul><li>Economical: nondisposable jig, the only cost is for the&nbsp;sutures and needle</li></ul><ul><li>Ergonomic: contoured handle facilitates jig placement</li></ul><ul><li>Anatomic: wide paddles ensure tendon capture by sutures</li></ul><ul><li>Efficient: colored sutures enhance suture management</li></ul><br><span><strong>Q. With the knotless technique, how do you ensure apposition of&nbsp;</strong><strong>the tendon ends after repair?<br></strong><br><strong>A</strong>. Regardless of the position of the tendon ends, the tendon will heal. If the tendon ends are far apart, scar will bridge the intervening defect.&nbsp;The goal, therefore, is not tendon apposition, the goal is restoration of&nbsp;appropriate length of the musculotendinous unit. This is best effected&nbsp;by draping the uninjured extremity into the sterile field and reproducing&nbsp;appropriate resting tension.<br><br>When using the crochet hook method, I would mildly over-tighten the&nbsp;repair, assuming suture creep and subsequent lengthening. With the&nbsp;locked suture of the PARS or the Knotless-PARS repair, I try to avoid&nbsp;<span>over-tightening as I feel that suture creep and late lengthening is unlikely.<br><br><strong>Q. What is your post-op protocol following Knotless-PARS repair?</strong><br><br></span><strong>A</strong>. Immediately postoperatively, patients are placed in a short leg cast ingravity equinus. On post-op day 3 – 5 they are placed in a CAM Walker with a modular Achilles wedge. PT starts day 5 – 7 with progressive ROM, strengthening, and proprioceptive exercises. The CAM Walker is&nbsp;removed at week 8 and activity as tolerated is allowed at week 12.&nbsp;<br><br></span><span><strong>Q. What do you see in the future of Achilles repairs?<br><br></strong><strong>A</strong>. The Midsubstance Achilles SpeedBridge is a big advancement in tendon repairs and is based upon the <em>Internal</em>Brace concept popularized by Gordon Mackay and Arthrex. By restoring appropriate soft tissue length/tension in a stable fashion, we can appropriately stress the repaired soft tissue (in this case, Achilles tendon). Early motion allows&nbsp;for avoidance of “cast disease” and results in a better organized tendon&nbsp;<span>with improved strength and flexibility.<br><br></span></span>In the future, we will learn to harness the body’s own mechanisms to&nbsp;improve healing. Preliminary results in an animal suggest enhanced healing of Achilles repairs with application of bone marrow aspirate concentrate. As we become more efficient in concentrating and activating&nbsp;the patient’s native stem cells, the speed and quality of tendon healing&nbsp;will dramatically improve.<br><span><span><span><br>* Article Reference:<br>Patel VC, Lozano-Calderon S, McWilliam J. Immediate weightbearing after modified percutaneous Achilles tendon repair.&nbsp;<span><em>Foot Ankle Int.</em> 2012;33(12):1093 – 1097.</span><br></span><br><br></span><br><br><br></span> Danielle Batsios Pain Evaluation After Arthroscopic All-Inside Anterior Cruciate Ligament Reconstruction <span>By Philippe Hardy, MD, PhD<br></span> <img alt="Dr. Hardy" class="pull-left" src="" style="padding: 7px;" width="115" /><br><span><span>The GraftLink? technique has several perceived advantages over traditional ACL reconstruction techniques due to the ability to preserve tissue and bone, harvest only a single hamstring, create smaller incisions and tension the graft into anatomic femoral and tibial sockets after fixation. Our recent prospective study, published in the<em> Knee </em>journal,</span><strong> </strong><a target="_blank" rel="nofollow" href=""><strong>Pain evaluation after all-inside anterior cruciate ligament reconstruction and short term functional results of a prospective randomized study</strong></a>(1), <span>quantified some of these advantages and showed a clear benefit of the GraftLink technique over a traditional, full tunnel technique with interference screws.&nbsp; <br><br></span></span> <img alt="GraftLink" class="pull-right" src="" style="padding: 7px;" width="200" />Overall, GraftLink patients exhibited a trend for less pain, better range of motion and improved knee stability in the early postoperative period. Socket position was also superior with the use of FlipCutter? versus standard antegrade reamers. At six months, patients exhibited excellent subjective scores as rated by the IKDC scale. These early results validate what we have experienced with our patients clinically and we look forward to comparing long term outcomes in the future. <span><span><br><br><br><strong><br>Article Reference:</strong><br>(1) &nbsp; &nbsp; &nbsp;</span><a target="_blank" rel="nofollow" href=""><strong>Benea H</strong></a><span><a target="_blank" rel="nofollow" href=""><strong>,&nbsp;</strong></a><a target="_blank" rel="nofollow" href=""><strong>d'Astorg H</strong></a><a target="_blank" rel="nofollow" href=""><strong>,&nbsp;</strong></a><a target="_blank" rel="nofollow" href=""><strong>Klouche S</strong></a><a target="_blank" rel="nofollow" href=""><strong>,&nbsp;</strong></a></span><a target="_blank" rel="nofollow" href=""><strong>Bauer T</strong></a><span><a target="_blank" rel="nofollow" href=""><strong>,&nbsp;</strong></a><a target="_blank" rel="nofollow" href=""><strong>Tomoaia G</strong></a><a target="_blank" rel="nofollow" href=""><strong>,&nbsp;</strong></a></span><a target="_blank" rel="nofollow" href=""><strong>Hardy P</strong></a><a target="_blank" rel="nofollow" href=""><strong>.</strong></a><a target="_blank" rel="nofollow" href=""><strong> Pain&nbsp;evaluation&nbsp;after&nbsp;all-inside&nbsp;anterior&nbsp;cruciate&nbsp;ligament&nbsp;reconstruction&nbsp;and&nbsp;short&nbsp;term functional&nbsp;results&nbsp;of a&nbsp;prospective&nbsp;randomized&nbsp;study. </strong></a><a target="_blank" rel="nofollow" href=""><em></em></a><em><a target="_blank" rel="nofollow" href=""><strong>Knee</strong></a></em><a target="_blank" rel="nofollow" href=""><strong>.</strong></a><a target="_blank" rel="nofollow" href=""><strong>&nbsp;2014;21(1):102-106.</strong></a><strong> </strong><br></span><span><br><br><br></span> Danielle Batsios Ankle TightRope Sports Update with Steven Martin, MD <h3> <img alt="Dr. Steven Martin" class="pull-left" src="" style="padding: 7px;" width="150" /></h3><strong>Q. What compelled you to use the TightRope on elite athletes with syndesmotic injuries?</strong><br><br><strong>A.</strong> Several factors, but first and foremost, I was never satisfied with the&nbsp;delayed weight-bearing status after traditional transosseous screw&nbsp;fixation of the syndesmosis. After any major injury, an athlete’s first question is when can I return to play? Our traditional short-term and&nbsp;long-term outcome measures of ankle fracture surgery all apply to the&nbsp;elite athlete but return to play time is extremely important as well.&nbsp;Second, the elite athlete, especially a skilled player position, needs a loaded range of ankle dorsiflexion of more than 20 degrees. The TightRope allows for more physiological motion at the distal tibiofibular joint. As a result of earlier weight-bearing and more normal joint kinematics, more ankle dorsiflexion range-of-motion is generally achieved. This is important for elite athletic performance.<br><br><strong>Q. When utilizing the TightRope, what features have you found&nbsp;most valuable?</strong><br><br><strong>A.</strong> First, I think you have to evaluate all implants on performance. The TightRope has allowed me to achieve immediate rotational stability of the ankle and lets me push earlier weight-bearing.&nbsp;Second, the implant has to be surgeon friendly from a technical standpoint. Insertion of the TightRope is quick, reproducible, and without any&nbsp;major technical problems.<br><br><strong>Q. We sometimes hear “I always use screws for syndesmosis injuries.” What would be your response to those conversations?</strong><br><br><strong>A.</strong> I think any time you use the term “always” in medicine you can be setting yourself up for potential failure. Single or double three and four cortices metal screws is, and has been for the last two decades, the gold standard treatment of displaced syndesmosis injuries. The problems associated with this technique however are numerous. Postoperative CT scans confirm malalignment of the syndesmosis in up to 50 percent of cases. Immediate weight-bearing is usually discouraged with the screws in place and screw breakage rates, if not removed, are also significant. Even though screws are still the gold standard, I think we&nbsp;must, at minimum, rethink our overall treatment strategy for these difficult&nbsp;ankle fracture patterns with syndesmotic injury. The TightRope has&nbsp;opened my eyes to a better understanding of the injury patterns seen&nbsp;and a treatment strategy that is more anatomically based.<br><br><strong>Q. Can you describe your return-to-play factor with the TightRope&nbsp;compared to screws?</strong> <img alt="Ankle TightRope Syndesmosis" class="pull-right" src="" style="padding: 7px;" width="225" /><br><br><strong>A.</strong> Every case, from a rehabilitation standpoint, has to be individualized. With my current surgical treatment of these injuries, which includes TightRope fixation of the syndesmosis and repair of the anterior inferior tibia fibular ligament, I am able to accelerate the rehabilitation and return-to-play timeline in a minimum 3 – 4 weeks. I can push the&nbsp;early postoperative rehabilitation protocol because I do not leave the&nbsp;operating room until I have achieved enough rotational stability to allow&nbsp;<span>immediate weight loading.<br></span><br><strong>Q. What is your rehabilitation protocol with the TightRope?</strong><br><br><strong>A.</strong> I follow a fairly simple rehabilitation protocol using my intraoperative assessment of fixation stability, pain, swelling, and range-of-motion as a guide to progression. The first two weeks, the patient is in a well-padded splint to maximize anti-swelling and early soft tissue healing. They are on crutches 30 – 50 lbs. partial weight-bearing. At two weeks, after suture removal, I place them in a pneumatic CAM Walker boot, begin range-of-motion and use of a stationary bicycle. Weight-bearing is allowed as comfort permits, with most athletes being full weight-bearing by four weeks. At four weeks, if they have greater than 10 degrees of dorsiflexion and are full weight-bearing, they start progressive resistive exercises and running in an aqua treadmill with the water at chest level. More aggressive proprioreceptive exercises and transition into a standard AFO occurs at around eight weeks. Flat inline running at 10 weeks and full agility and sports specific activities at 12 – 14 weeks. This program can be accelerated if immediate rotational stability is achieved in the operating room. Depending on fixation and stability on the medial side of the ankle, specifically the deep deltoid, this program, especially weight-bearing&nbsp;may need to be delayed 3 – 4 weeks.<br><br><strong>Q. When you spoke at the 2014 NFL Combine about ankle, injuries&nbsp;what excited the audience?</strong><br><br><strong>A.</strong> Foot and ankle injuries are a huge problem in the NFL. The number of player days missed, secondary to high ankle sprains and ankle fractures is tremendous. I think any treatment advances that allow earlier player return is looked on with excitement. High ankle sprains are another big impact area. There is potential for the TightRope and <em>Internal</em>Brace?&nbsp;Ligament Augmentation Repair to have a role in the higher-grades of&nbsp;ankle sprain injuries. The current difficulty is identifying which injuries, in&nbsp;which player positions and at what time in season would benefit from&nbsp;surgical intervention.<br> Danielle Batsios Advances Allow for Safe and Successful Outpatient Partial Knee Replacement Procedures <img alt="Dr. Valadie" class="pull-left" src="" style="padding: 7px;" width="175" /><strong>By Alan L. Valadie, MD<br><br></strong>As a result of our more and more active society as well as injuries suffered in sports, we are seeing more patients with early wear and tear of their joints. This is especially true in the knee, and we are seeing higher numbers of patients with osteoarthritis of the knee limiting their activities. Fortunately, we have many nonsurgical measures to help manage the pain of arthritis. In a&nbsp; <img alt="golfer" class="pull-right" src="" style="padding: 7px;" width="225" />growing&nbsp;number of patients, however, the breakdown is severe enough that knee replacement is necessary to continue activities. While this procedure is typically successful, it may not restore the normal level of activities desired. &nbsp;In 10 percent to 20 percent of patients with knee arthritis, however, the breakdown of the cartilage in the knee is limited to just one area. This typically involves the inner or medial aspect of the knee, although can involve the outer (lateral) part of the knee or underneath the kneecap.<br><br>In these patients, a partial knee replacement may be an option. In this procedure, just a small part of the knee is resurfaced. With advances in technology, procedures and pain management, this can now be done safely and successfully as an outpatient. For over a year, we have been performing this procedure with great success in our outpatient surgical center. Patients are discharged from the surgical center to recover in the comfort of their own home. In addition, this allows them to avoid hospitalization and minimize the risk of potential complications such as infection. &nbsp; <br><br> <img alt="golfer" class="pull-left" src="" style="padding: 7px;" width="225" /><span>Important elements for successful outpatient procedures such as this include a healthy, motivated patient with a home environment suitable for appropriate recovery. One aspect of this is family who can assist with exercises and mobilization, which start immediately upon arrival home. Also important is a surgical center and surgeon who have assembled processes and protocols to safely and effectively perform these procedures. Finally, implant and instrumentation systems designed for minimally invasive procedures are critical. The Arthrex <a target="_blank" rel="nofollow" href="">iBalance unicondylar knee system (UKA)</a> is an example of a system built on efficiency, reliability and ease of use. In the outpatient setting, this facilitates consistent and reproducible results.</span> Danielle Batsios What's In My Bag? With Thomas Clanton, MD, and Kent Ellington, MD <h3><strong><em>Internal</em>Brace Ligament Augmentation Repair</strong></h3> <img alt="ThomasClanton" class="pull-left" src="" style="padding: 7px;" width="150" /><strong>Q. Why have Brostroms been considered the gold standard when some&nbsp;of the literature indicates that patients have to step down in their&nbsp;activities?<br></strong><br><strong>Dr. Clanton:</strong> The Maffulli article in&nbsp;<em>The American Journal of&nbsp;Sports Medicine</em> (AJSM)&nbsp;is one of the only articles&nbsp;that includes a long-term outcomes analysis of the Brostrom procedure&nbsp;and suggests such a reduction in activity (42%). Most other studies, which look at shorter term results, generally have reported success&nbsp;rates ranging from 85-95% with the Brostrom procedure or with the&nbsp;Gould modification of this procedure.<br><br><strong>Dr. Ellington:</strong> I would not call it a complication, but could be considered&nbsp;a failure. Patients want their instability corrected. The Brostom does&nbsp;this well; however, if patients have improved stability, yet cannot return&nbsp;to their previous level of activity/function, then the gold standard&nbsp;seems “tarnished.”<br><br> <img alt="KentEllington" class="pull-left" src="" style="padding: 7px;" width="150" /><strong>Q. What compelled you to use the<em> Internal</em>Brace construct to&nbsp;augment your Brostroms?<br><br>Dr. Clanton: </strong>After hearing Dr. Gordon Mackay’s presentation on the <em>Internal</em>Brace concept, we performed biomechanical testing that confirmed the improved strength of the augmentation. This was&nbsp;recently published in the February issue of <em><a target="_blank" rel="nofollow" href="">The American Journal of&nbsp;Sports Medicine</a></em>.<br><br><strong>Dr. Ellington:</strong> I needed an augment (because of the stated failures&nbsp;above). I traditionally used the Evans procedure (split transfer of the&nbsp;brevis to the fibula). I never really liked this…it wasn’t anatomic, it&nbsp;sacrificed a tendon and you can make patients too tight. I decided&nbsp;to first use it in my work comp and revision Brostroms and when I&nbsp;experienced great success in these patients (more difficult patients) I was surprised actually. From there, I have now adopted to using&nbsp;<span><em>Internal</em>Brace in all my cases.<br><br><strong>Q. We often hear “I never met a Brostrom that needed augmentation” OR&nbsp;“My Brostroms all do fine.” Knowing the clinical value, what would&nbsp;be your response to those conversations?</strong><br><br><strong>Dr. Clanton:</strong> The Brostrom procedure has been an excellent procedure&nbsp;over the short-term, but does not work in all situations. For example, it is not appropriate for patients who are reinjured and have instability&nbsp;following prior ankle reconstructions. I also do not favor the Brostrom&nbsp;technique in patients who are hyperflexible. In my opinion, we should&nbsp;always be vigilant for methods by which we can improve the results of&nbsp;what we do for our patients.<br><br><strong>Dr. Ellington:</strong> The literature&nbsp;doesn't&nbsp;support such claims and once&nbsp;I thought the same. These patients rarely come back after initial&nbsp;follow-up. However, I strongly believe that although their instability has&nbsp;improved, some are not happy with their outcome because of inability&nbsp;to return to previous level. These patients likely choose not to return to&nbsp;<span>see their doctor.<br><br><strong>Q. It is understood that this procedure is relatively new with limited, long-term clinical follow-up. Can you comment on the outcomes and your experience with your patients you have treated? Please explain&nbsp;the difference between standard Brostrom repair and those that have</strong><em><strong>&nbsp;Internal</strong></em><strong>Brace?</strong><br><br><strong>Dr. Clanton: </strong>While the procedure is relatively new for the ankle, it&nbsp;has been used in other areas such as the shoulder and for the Achilles&nbsp;tendon with good results and few negative outcomes.<br><br><strong>Dr. Ellington:</strong> I have used <em>Internal</em>Brace on around 25 patients, most with long-term follow-up. Without a doubt, they have increased stability.<br><br></span></span> <img alt="InternalBraceShoe" class="pull-right" src="" style="padding: 7px;" width="350" /><span><strong>Q. What have been the most positive effects of the </strong><em><strong>Internal</strong></em><strong>Brace for&nbsp;your patients?</strong><br><br><strong>Dr. Clanton:</strong> In my patients, the most positive aspect of the <em>Internal</em>Brace&nbsp;has been less worry (for the patient and me).<br><br><strong>Dr. Ellington:</strong> Confidence in the ankle.<br><br><strong>Q. Surgeons often speak of clinical studies before trying something new. Why try the</strong><em><strong> Internal</strong></em><strong>Brace now? What are the minimum expectations&nbsp;you have?</strong><br><br><strong>Dr. Clanton:</strong> Fortunately, there are now biomechanical studies that&nbsp;support the use of the<em> Internal</em>Brace and there are individuals such as&nbsp;Drs. Mackay, Coetzee, Gates, Vora, and Ellington who have extensive&nbsp;experience with the technique in the lateral ankle as well as other&nbsp;locations.<br><br><strong>Dr. Ellington:</strong> It should be tried because the standard Brostrom has solid evidence that it is not as good as we think. The minimum&nbsp;expectations are no additional complications from using the&nbsp;<em>Internal</em>Brace, easy application of the system.<br><br><strong>Q. What are the technique pearls you have learned and can pass&nbsp;along?</strong><br><br><strong>Dr. Clanton: </strong>It is important to follow the recommendations for exactly how to perform the technique, and to understand the anatomy and biomechanical function that one wishes to restore. It is certainly possible&nbsp;to place the augmentation in an incorrect position and over-constrain&nbsp;the joint. Dr. Mackay’s technique of keeping a hemostat under the&nbsp;FiberTape? during the insertion of the second SwiveLock seems to help&nbsp;in avoiding this.<br><br><strong>Dr. Ellington:</strong> The talus is a hard bone. When I tap the talus, I leave the tap in while I insert the system into the fibula. This allows the talus&nbsp;to “stretch” a little, making the placement of the talus implant a little&nbsp;<span>easier.<br><br><strong>Q. In simple terms, explain your surgical technique.</strong><br><br><strong>Dr. Clanton:</strong> I perform the Brostrom procedure and augment it with the<em>&nbsp;Internal</em>Brace placed over the top of the ATFL arm of the Brostrom.<br><br><strong>Dr. Ellington:</strong> I repair my ATFL with 3.0 suture anchor. Then drill and tap (leave tap in) the talus. Next I drill and tap the fibula. I place the fibular side, line up the talus side (making mark a on FiberTape with surgical marker). I remove talus tap, place talus implant, with hemostat&nbsp;under and with the ankle in slight plantar flexion and inversion to prevent&nbsp;<span>overtightening.<br></span><br><strong>Q. Have you considered <em>Internal</em>Brace for other indications (Spring Ligament, Deltoid Ligament, and/or Lateral Ankle with Arthroplasty)?</strong><br><br><strong>Dr. Clanton:</strong> I have used the <em>Internal</em>Brace in all of those situations and it&nbsp;has been very effective.<br><br><strong>Dr. Ellington:</strong> Yes, I have done three for spring ligament.<br><br><strong>Intra-op:</strong> I place one limb plantar to dorsal with the FDL and the other&nbsp;dorsal to plantar. I hold the foot in slight plantar flexion/inv as I tension.&nbsp;Placing the calcaneus tunnel is verified first by finding the sustentaculum&nbsp;tali directly, then confirming by placing a small guide wire and checking&nbsp;a lateral and axial heel view. Then I remove the wire and drill.<br><br><strong>Post-op:</strong> Awesome corrections. Fully weight-bearing — radiographic parameters much better than those without spring ligament repair. I now do on all flatfoot reconstruction. I’m starting to believe that this could replace the need for a lateral column lengthening (Evans) in some cases. It really improves talonavicular uncoverage.</span></span> Kristin Bartlett What’s In My Bag with Gregory S. DiFelice, MD <h3> <img alt="Dr. Gregory DiFelice" class="pull-left" src="" style="padding: 7px;" width="150" /><em>ACL Preservation</em></h3><span><span> <span><strong>Q:</strong><em><strong> </strong></em><strong>Dr. DiFelice, with your recent release of the technique manual,&nbsp;</strong><a target="_blank" rel="nofollow" href=""><strong>ACL Primary Repair</strong></a><strong>, it seems that you are challenging the current treatment standard of reconstruction for ACL rupture.&nbsp; Do you think that arthroscopic ACL preservation&nbsp;will become&nbsp;the new standard of treatment?</strong></span><br> &nbsp;<br> <strong><em>A:</em></strong> <em>Not at all. The procedure that I have described is an arthroscopic method of reattaching the ACL back to its native origin or insertion using suture anchors. It is really only applicable to avulsion or "peel off" type tears and will never become the standard of care for ACL tears, in general, since&nbsp;the majority of them are mid-substance tears that is not effective for this technique. However, it is a nice tool to have in your surgical toolbox.</em><strong><em><br> </em></strong><em>&nbsp;</em></span><span><br> </span><strong>Q:</strong> <strong>Isn’t there a lot of historic experience regarding ACL repair that led us to migrate our treatment towards reconstruction? Aren't&nbsp;you just repeating history here?</strong><em><span><br> &nbsp;<br> <strong>A:</strong> I would certainly like to think not. The historic treatment of ACL repair was done as an open procedure and the studies looking at outcomes were significantly limited by the techniques, and knowledge base of the time. Looking back, the studies had significant bias that limited the conclusions that could be drawn. The paper considered to be the landmark paper on ACL repair at the time, by&nbsp;<a target="_blank" rel="nofollow" href="">Mark Sherman et al</a>&nbsp;</span></em>(</span>1)<span><em><span>, was the only one to analyze subgroups, and suggested that proximal tears with excellent tissue quality had a much better chance of positive outcomes. This is the group that I have focused on.<strong><br> </strong></span></em>&nbsp;<span><br> <strong>Q:</strong> <strong>How do you perform the procedure?</strong></span></span><strong> <img alt="ACL Primary Repair" class="pull-right" src="" style="padding: 7px;" width="200" /></strong><br><span><em> <strong>&nbsp;</strong><strong><br> <strong>A: </strong></strong>I liken the procedure to performing a rotator cuff repair in the knee. In fact, this is how I came up with it. I do a lot of shoulder work and thus, I simply migrated the shoulder instrumentation to use in the knee.&nbsp; I use a Scorpion FastPass to pass a locking Bunnell type stitch of #2 FiberWire into each bundle of the ACL. Then, I retension the bundles to their respective origins using 4.75 BioComposite Vented SwiveLock.<strong><br> </strong>&nbsp;<strong><br> </strong></em><strong>Q:</strong> <strong>You recently reported your early results at the International ACL Study Group meeting in South Africa. Can you share a little about your experiences, thus far?</strong><em><br> &nbsp;<br> <strong>A: </strong>To date, I have performed this procedure on 32 patients. Follow-up is from one week to six years. In South Africa, I presented on my first 15 patients with an average of 24 months follow-up. To my knowledge, this is the first ever report of&nbsp;</em></span><em>arthroscopic ACL preservation</em><strong><em>&nbsp;</em></strong><span><em>for complete ACL tears performed on human beings. I had one early failure in a noncompliant patient, and one patient who was stable at&nbsp;three months, but lost to follow-up, thereafter. Everyone else is stable and functioning well with outcome scores in the 90s. There have been no other failures in the larger group to date, although follow-up is shorter.<strong><br> </strong>&nbsp;<br> </em><strong>Q: Your experiences would suggest this is a promising technique. What are your thoughts looking forward?</strong><em><br> &nbsp;<br> <strong>A: </strong>Caution must be used in interpreting the data thus far. This is a small, retrospective series with short-term follow-up. However, the data is promising. The technique, although limited by injury pattern, makes sense from a biologic standpoint and opens the door to a new way of thinking about the ligament remnant. Hopefully, it will provide a spark to ignite a new body of research with a more biologic focus to&nbsp;our treatment of ACL injuries.</em></span>&nbsp;&nbsp;<br><br>1. Sherman MF, Lieber L, Bonamo JR, Podesta L, Reiter I.<em>&nbsp;</em>The&nbsp;long-term&nbsp;followup&nbsp;of&nbsp;primary&nbsp;anterior&nbsp;cruciate&nbsp;ligament&nbsp;repair.&nbsp;Defining&nbsp;a&nbsp;rationale&nbsp;for&nbsp;augmentation.<em>&nbsp;</em><em>Am J Sports Med</em>. 1991; 19(3): 243-255.&nbsp;<br><br><h1><span> <br> </span></h1><br><br> Danielle Batsios ACL preservation making resurgence with advances in diagnostic imaging, all-arthroscopic surgical technology and rehabilitation approaches <em><strong>By Gregory S. DiFelice, MD</strong><br></em><br> <img alt="DiFelicePrimaryACLRepair" class="pull-right" src="" style="padding: 7px;" width="250" />My interest in ligament repair was really born of my particular clinical setting. My practice is a rather trauma-heavy sports medicine practice with a majority focus on knee and shoulder that is located in a level one trauma center. Early in my career, I found myself faced with a large burden of multiligamentous knee injuries to treat. At that time, our ability to address these injury patterns was not as developed as it is today and when I was faced with ligamentous avulsions, largely the PCL off of the femur, I would make an effort to primarily repair it. This need, when combined with my facility using the arthroscopic shoulder instrumentation, led to my first attempts at arthroscopic primary cruciate repair. <br> <br>I had good clinical success whenever I attempted primary PCL repair. The knees were certainly as stable, if not more stable, than the reconstructions of the time. There were also a few ACLs that were avulsed either proximally or distally that I fixed during this time, also with good results. However, I was fully aware that the multiligamentous knee setting was not a comparable clinical scenario to an isolated ACL tear. This success was predicated on apposing a freshly avulsed ligament back into a bleeding bony bed, and to me made good biologic sense. A loose analogy could certainly be drawn to performing a rotator cuff repair, and much of the same biologic ingredients were present to predict a high likelihood of healing.<br><br><span>My early successes with primary cruciate repair sparked my interest in whether or not such a technique would work on isolated ACL tears, a much more common clinical problem than the multiligamentous injured knee. Open ACL preservation was the recommended treatment for an acute ACL rupture in the later 1970s and early 1980s; however, the procedure was largely abandoned due to unpredictable clinical results. A thorough review of the older literature convinced me that the conclusion to abandon this procedure was flawed, when viewed through the prism of our current knowledge base. Despite all of the limitations of these studies, it should be noted that on average, roughly 50 percent of these patients had excellent results, even to the long-term follow up. The trouble was predicting which 50 percent had excellent results. The only paper that looked at predictive variables was that of <a target="_blank" rel="nofollow" href="">Mark Sherman et al</a>.<strong><em>1&nbsp;</em></strong>They found that it seemed to be that patients who were older than 22, who had a skiing injury and had proximal type 1 tears with excellent tissue quality, had a much higher likelihood of excellent results. This observation dovetailed nicely with my experiences repairing proximal tears in the multiligament injured knee setting.<br></span><br>I also did a review of the current literature over the past decade on the subject of ACL preservation. I found mostly animal studies from Martha Murray’s lab in Boston that suggested that there might be a role for a biologically augmented ACL preservation. There were also some long-term follow-up studies on the older cohorts confirming approximately 50 percent good to excellent results. Interestingly, there are no new clinical studies on humans regarding primary repair of complete ACL tears in the literature that I am aware of in the past 15 years or more. It was my review of the literature, old and new, that gave me the determination to proceed with expanding my arthroscopic cruciate preservation indications.<br> <br>The perfect candidate was referred to me about six years ago. He was a 42-year-old skier who was still very active and had an acute, proximal ACL avulsion. I explained to him my experience, my reasoning, and the expected outcomes. I gave him full disclosure of the risks, the benefits and alternatives and he wanted me to proceed with attempted arthroscopic primary ACL preservation. I passed two #2 FiberWire? in a locking fashion with the older Scorpion?, passed them through drill holes and tied them over a ligament button at the lateral cortex. The patient ended up with a completely stable knee, and to this day continues to function well, without any instability symptoms.<br> <span><br>As the years have gone by and Arthrex has continued to expand its complement of arthroscopic instrumentation, my technique has been improved and was recently described in the <a target="_blank" rel="nofollow" href="">ACL Primary Repair Surgical Technique Guide</a>&nbsp;and in the <a target="_blank" rel="nofollow" href="">ACL Primary Repair Surgical Technique Vide</a><a target="_blank" rel="nofollow" href="">o</a>. My current technique involves passing a Bunnell type stitch of #2 FiberWire? using the Scorpion? FastPass into each bundle of the avulsed ACL. These are then tensioned and fixed at their respective former origins utilizing 4.75 BioComposite? SwiveLock?. Currently, I have performed approximately 35 arthroscopic ACL preservations for isolated tears using this technique and have had excellent results to date. As my clinical successes increased, so too did my indications and I now base the indication for surgery most heavily on tear pattern and acuity, rather than other variables. <br></span> <br>Based on my experience, I am excited that this may be the beginning of a new step in our collective approach to ACL injury. It is my hope that this experience will bring an increased awareness that it is possible to repair certain patterns of ACL injury with a reasonable expectation of success. These tear patterns are easily identifiable on MRI and can be preserved using my technique or a modification thereof. Rather than abandon the concept of ACL preservation like in the past, I think that we can learn from the historic experience and revisit the concept with a better understanding. Perhaps we can now diagnose those patients who have an excellent chance of benefiting from ACL preservation and reserve the more invasive reconstructions for only those patients who truly need it. This is certainly an intriguing concept, and in light of the advances in diagnostic imaging, arthroscopic surgical technology and rehabilitation approaches that have come to the forefront over the past several decades, ACL preservation is a concept that is ripe for reevaluation.<br><br><blockquote>1. Sherman MF, Lieber L, Bonamo JR, Podesta L, Reiter I.<em> </em>The&nbsp;long-term&nbsp;followup&nbsp;of&nbsp;primary&nbsp;anterior&nbsp;cruciate&nbsp;ligament&nbsp;repair.&nbsp;Defining&nbsp;a&nbsp;rationale&nbsp;for&nbsp;augmentation.<em> </em><em>Am J Sports Med</em>. 1991; 19(3): 243-255.&nbsp;</blockquote> Kristin Bartlett Get Your 2013 "What's New" Year in Review Newsletter <img alt="Anniversary" class="pull-right" src="" style="padding: 7px;" width="250" />Every single day in 2013, Arthrex featured an exciting new orthopaedic product and/or surgical technique through our weekly "What's New" email newsletter; a testament to Arthrex's never-ending commitment to constant innovation in the orthopaedic industry. <br><strong><br>In celebration of the past year of innovations, upcoming anniversary editions of our weekly "What's New" newsletter will highlight the <u>top 12 features over the past year</u>. </strong>It will include our most popular&nbsp;surgical technique videos, presentations and&nbsp;demonstrations by leading orthopaedic surgeons from around the world.&nbsp;<strong><a target="_blank" rel="nofollow" href="">Get your copy by subscribing here</a></strong><strong>.&nbsp;</strong><em>If you are already subscribed to our newsletter, please be sure that your contact information is&nbsp;current by<a target="_blank" rel="nofollow" href=""> updating your account information here</a>.&nbsp;</em><br><br><strong>The Arthrex website&nbsp;also features a What's New section that showcases daily updates on new product releases, surgical techniques and related science.</strong> These features along with past archives,&nbsp;can be found on our homepage, <a target="_blank" rel="nofollow" href=""></a>, or at&nbsp;<a target="_blank" rel="nofollow" href=""></a>. You can also follow us on Twitter - <a target="_blank" rel="nofollow" href="">@ArthrexWhatsNew</a>.<br><br>Arthrex is excited for what is to come in 2014 and continuing&nbsp;our mission of&nbsp;helping surgeons treat their patients better through product and technique innovation!<br> Kristin Bartlett What's In My Bag with William T. Pennington, MD <img alt="Pennington" class="pull-right" src="" style="padding: 7px;" width="400" /><strong>Q. How has the implementation of SynergyHD3 impacted your practice?</strong><span><strong>&nbsp;</strong><br><br>A. Our hospital, the Midwest Orthopedic Specialty&nbsp;</span>Hospital (MOSH), is a joint venture with 50/50 ownership between a physician investment group and Wheaton Franciscan Health Care. When creating our hospital, it was our mission to put the patient first and develop all of our care pathways with the thought of&nbsp; delivering the highest quality, state-of-the-art orthopaedic care to our patients that would ultimately lead to superior clinical results and patient satisfaction. Implementing the most&nbsp; current surgical methods, as well as remaining on the cusp of all&nbsp; developing technology, has certainly assisted us in our efforts to become a center of excellence in orthopaedic care. Our efforts focusing on quality delivery of patient care has been acknowledged by being awarded the prestigious Press Ganey Inpatient Summit Award in 2012. Since the implementation of&nbsp; SynergyHD3 &nbsp;with the Physician App into our arthroscopic program, our Press Ganey outcome scores measuring patient satisfaction have improved 7% in mean score and 193% in percentile ranking. These measurements are representative of patients who have been queried about the information that&nbsp; was communicated to them regarding their surgery vs. our “pre-SynergyHD3” benchmarking scores. We have also recently begun utilizing&nbsp;<span> SynergyHD3 with the Physician App in our open procedures, as well with the same enthusiastic response from patients regarding their satisfaction with being informed as to what occurred in their surgical procedures.<br></span><br><strong>Q. MOSH no longer prints hard copy images following the procedure. Has the decision to move to digital images been a positive transition? What has been the reaction from your patients?</strong><br><span><br>A. The aspect of not having to print images is something that we, and our patients, have embraced. Images immediately exported to our hospital EMR, the practicing physician’s EMR and to the patient via HIPAA secure methods has significantly improved our efficiency, while also decreasing the cost to our hospital and practices incurred from paper and ink purchases. In addition, personnel time and cost is no longer being required to scan images into the patient’s record. Patients also have responded quite favorably to the immediate availability of their&nbsp;</span><span> annotated surgical images.<br></span><br><strong>Q. When utilizing the patient app, what features have you and your partners found most valuable?</strong><span><strong>&nbsp;</strong><br><br>A. We have utilized the app to not only provide patients with postoperative annotated images, but also have included links to postoperative instruction sheets pertaining to their particular procedure, YouTube videos of our therapists teaching them immediate exercises and educational technique videos through the <a target="_blank" rel="nofollow" href=""></a> site. Again, these features have provided great satisfaction to our patients&nbsp;</span><span>and helped their ability to navigate the peri-operative period with less stress.<br></span><br><strong><em>Dan Mattes, CEO Wheaton Franciscan and MOSH<br></em></strong><br><strong>Q. What has the&nbsp;impact of SynergyHD3 been at MOSH?:</strong><span><strong>&nbsp;</strong><br><br>A. While developing our program at MOSH, we have set up a structure in which we evaluate all of our outcome scores of patient satisfaction&nbsp;</span>diligently and proactively and react to deficiencies in our care delivery as reported by our patients. As stated previously, we were not performing to our standards on our postoperative surveys when it came to patients feeling that they were adequately informed as to what was done to them in the operating room. Since implementing SynergyHD3, we have noticed that our Press Ganey patient-satisfaction scores pertaining to these measures have improved drastically. Since the passage of the Affordable Health Care Act, patient reimbursement will be correlated with patient satisfaction. As an administrator, I feel the SynergyHD3 investment has been quite valuable and will have an unlimited ceiling as we increase its implementation to more of our open procedures as well. Another aspect of the improved postoperative education that we are able to provide through our SynergyHD3 reports is our ability to hopefully curb hospital re-admissions by the inclusion of all of the postoperative educational links.<br><br><strong>Q. Arthrex recently released an open surgical video platform. Can you share some feedback on this cutting-edge&nbsp;</strong><span><strong>technology?</strong><br></span><span><br>A. We have recently begun utilizing the SynergyHD3 platform during open procedures (ie: Total Shoulder Arthroplasty). From a patient educational standpoint, it has been quite a success as we have been able to generate similar reports including images and video documenting preoperative motion, post-implantation motion and selected still photos and video clips for the patients. This gives the patient a better understanding as to what was done. We have also been able to include similar educational links to the patient reports, including YouTube videos of our therapists demonstrating home therapy programs and postoperative instruction sheets, with hopes of curbing hospital re-admissions and achieving a higher level of patient satisfaction.&nbsp;</span>Prior to incorporating SynergyHD3, the anesthesiologists were not typically able to see deep into the surgical field, during a glenoid exposure, for example. Our anesthesiologists appreciate being able to directly view the surgical field, which allows them to respond to our needs in a proactive manner.&nbsp;<br><br><br><em>We regret to inform our readers of the untimely passing of Dan Mattes, president of Wheaton Franciscan Healthcare central market and Scope This Out contributor. Our sincere condolences are extended to Dan’s family, Dr. William Pennington and the entire Wheaton Franciscan Healthcare community.</em> Kristin Bartlett New Research Renews Interest in the Anterolateral Ligament of the Knee <span> <img alt="Anterolateral_Ligament" class="pull-right" src="" style="padding: 7px;" width="250" />Dr. Steven Claes' (University of Leuven, Belgium)&nbsp;recent award-winning research has further defined the anatomy and function of the Anterolateral Ligament (ALL).&nbsp;Writing in the&nbsp;<strong><em><a target="_blank" rel="nofollow" href="">Journal of Anatomy</a></em></strong>, Dr. Claes suggests the fibrous band could play a part in one of the most common sports injuries worldwide.</span> <br><span><br>“Despite glimpses of the ligament in medical history, this is the first time its structure and purpose have been so clearly established,” Claes says.</span> <br><br>For some patients, rupture of the ACL and ALL may cause excess joint laxity that may not be resolved with ACL reconstruction alone. Working with Dr. Claes, as well as other leading knee surgeons, Arthrex has developed minimally invasive reconstruction techniques to address this pathology and will be releasing an instructional video by Dr. Claes in the coming days. <br><br><strong>Read more: </strong><br><span><em>Ku Leuven</em>: <a target="_blank" rel="nofollow" href=""></a></span> &nbsp; <br><span><br><em>BBC News Health</em>: <a target="_blank" rel="nofollow" href=""></a> </span> &nbsp; <br><br><em>NY Times</em>:&nbsp;<a target="_blank" rel="nofollow" href=""></a><br><span><br><em>Huffington Post</em>: <a target="_blank" rel="nofollow" href=""></a></span> &nbsp; <br><span><br><em>Science Daily</em>: <a target="_blank" rel="nofollow" href=""></a></span> &nbsp; Danielle Batsios Same-Day Outpatient Unicondylar Knee Replacement by Thomas&nbsp;DeBerardino, MD<br><br> <img alt="OutflowColorCoding" class="pull-right" src="" style="padding: 7px;" width="215" />Previously, partial knee replacements required a one- to three-day inpatient hospital stay. After discharge, a full recovery would take six weeks. The novel Arthrex iBalance Unicondylar Knee Arthroplasty (UKA) surgical technique, however, allows patients to undergo a partial knee replacement as a true same-day surgery procedure, enabling the patient to leave walking on their knee that same day.&nbsp;<br><br>The Arthrex iBalance UKA System is a complete, minimally invasive instrument and implant system for the treatment of localized unicondylar cartilage degeneration secondary to osteoarthritis or post-traumatic arthrosis in the medial or lateral compartments of the knee. The iBalance UKA System incorporates anatomic femoral and tibial resurfacing implants and a unique and innovative instrument set that facilitates a highly accurate, efficient and reproducible surgical technique. The instrumentation set is minimalistic and elegantly designed to be intuitive for the surgeon and OR staff, helping to shorten the learning curve and improve the OR workflow to reduce anesthesia times. The iBalance UKA System provides a predictable, balanced result that ensures near-natural kinematics of the operative knee compartment.<br><br> <img alt="OutflowColorCoding" class="pull-left" src="" style="padding: 7px;" width="250" />Through a small 3-4 inch parapatellar arthrotomy, surgeons gain excellent exposure to begin the removal of the medial or lateral femoral condyle and damaged cartilage via three simple bony cuts. The tibial plateau is prepared with a sagittal and horizontal bony cut. Appropriate implant sizing is then performed according to the patient’s measurements. The missing portion of the bone and cartilage is replaced with the iBalance Uni femoral trial and tibial bearing trial before cementing the final femoral and tibial components in place. This complete and innovative technology allows patients to have a better, more comfortable recovery at home and avoids a more invasive and painful surgery. The iBalance UKA method removes less bone than traditional methods, allowing patients to recover quicker so they can return to their normal quality of life faster.<br><br>Our anesthesia colleagues use regional blocks and light, general anesthesia, allowing patients to go home within an hour of surgery, pain free, with only a soft dressing and crutches for ambulatory assistance. Patients return on postoperative day one or three for their first wound check, bearing full weight on the operative leg using only crutches for support. Patient satisfaction has been universally very high, remarking how much they appreciate the fact that the iBalance UKA System allows for a minimally invasive procedure that negates the need for hospital admission.<br> Danielle Batsios The Arthrex Univers Revers?: A Historical Perspective <img alt="Univers_Revers" class="pull-right" src="" style="padding: 7px;" width="200" />Authors:&nbsp;<strong>Anthony Romeo, MD and Brian Cohen, MD<br></strong><br>More than a decade ago, Arthrex initiated the Univers Shoulder Arthroplasty System in the United States. Total joint replacement was new to the Arthrex product line at that time, but the Univers reflected the typical innovation and creative shoulder product development that has set Arthrex apart from its competitors. Now, a decade later, Arthrex is introducing its newest addition to the Univers System, the Revers Total Shoulder Arthroplasty System. This unique system is the result of more than four years in design and development, beginning with the collaboration between incredible engineers, product managers, Peter Habermeyer and myself, with many contributions from other innovative surgeons, including Dr. Brian Cohen from Chillicothe, Ohio. The Univers Revers development was stimulated by the need for a system that could help surgeons treat their patients better when the rotator cuff function is deficient or absent, especially if the glenohumeral joint was arthritic.<br><br>There is an old adage that says there are three sides to every story “your side, my side and then the truth.” When there is incomplete data, we make decisions based on our experience, the experience of others, and whatever scientific data is available to provide a framework for our surgical plan. The use of the reverse shoulder replacement for the treatment of the various shoulder pathologies is not protected from this concept, and in fact, it is the belief that there exists more than one way to accomplish the surgical goal of a stable joint that provides the potential for maximum function that leaves the discussion on neck angles, lateralization, inferior tilt, cemented vs. press-fit, two screws, three screws or four screws for baseplate fixation, an open-ended question.<br>&nbsp;&nbsp;<br> <img alt="Univers_Revers" class="pull-left" src="" style="padding: 7px;" width="200" />The Arthrex Univers Shoulder Arthroplasty System was designed and developed to answer the many questions that remain, as well as avoid complications of previous systems. &nbsp;It is the versatility of the Arthrex Univers Revers that makes this system unique in its field. &nbsp;It allows the surgeon to use their understanding of what is important to achieve a successful reverse shoulder replacement for their patients and maximize the options of the Arthrex Univers Revers system to accomplish this ultimate goal.<br>&nbsp;&nbsp;<br>On the glenoid side, the surgeon can choose from three baseplate sizes, to fit their patient’s glenoid anatomy. There is no concern of over or under sizing and the three options allow the surgeon to also accomplish maximum screw fixations with the three locking screw design (4.5 mm locking screws superior and inferior and a 6.5 mm central locking screw). This is the only system available that offers three glenosphere diameters (36 mm, 39 mm, 42 mm). For each size there are three glenosphere options (central, lateralized and offset). Although at “face value” all these options may be “dizzying,” it is in fact this variety that gives the orthopaedic shoulder surgeon the ability to address the expanded indications for a reverse shoulder patient head on, and removes the need to fit a “square peg into a round hole.”<br><br>On the humeral side, the two available neck angles (135 degree and 155 degree) once again give the surgeon options that are not available in other systems. The clinical concern of scapular notching is becoming more evident with our critical evaluation of patients treated early on with the reverse shoulder and the 135-degree neck angle has definitely shown to decrease the incidence of scapular notching. In fact, it was during one of the first revision cases that the surgeon was unable to reduce the 155-degree humeral trial and by simply adjusting the humeral implant angle of the trial to 135 degrees, reduction was easily accomplished. This eliminated the need for the surgeon to have to use a smaller diameter glenosphere and risk exposing their patient to an increased risk of instability.<br>&nbsp;&nbsp;<br> <img alt="Univers_Revers" class="pull-right" src="" style="padding: 7px;" width="200" />It is well recognized that the amount of offset seen in the proximal humerus has a wide range from anterior to posterior. The Arthrex Univers Revers has a unique ability to address humeral offset, allowing the component to sit centrally in the patient’s humeral metaphysis, which allows forces across the glenohumeral joint to be evenly distributed. Finally, the “trapezoidal” design of the metaphyseal portion of the humeral component gives it the ultimate press-fit fixation within the proximal humerus, avoiding the need for cement in the majority of cases.<br>&nbsp;&nbsp;<br>In closing, the ability to achieve a successful outcome after reverse shoulder arthroplasty is dependent on many factors, including the surgeon’s own experience and ability to adjust the procedure to their concepts and the patient’s pathology. The surgeon’s skill at addressing these variables comes not only from their training, but also from their intra-operative and postoperative experiences. The Arthrex Univers Revers Shoulder replacement system gives the surgeon the tools and the flexibility to accomplish their goals based on their training and their experiences, helping them treat their patients better than ever before.<br> Kristin Bartlett Arthrex Redefines Medical Education with Release of Interactive eBooks <img alt="ArthrexiBooks" class="" src="" width="659" /><br><br>Medical schools across the country have started to integrate the iPad into their curriculum and educational setting. The benefits are obvious and far reaching. Students can access entire libraries of learning material from their mobile device, collaborate with each other and consume content in creative new ways that didn’t exist before. eReader applications such as Apple’s iBooks App allow for the consumption of fully interactive digital textbooks. Image galleries, videos, animations and 3D objects can all be part of iBooks and provide an engaging and immersive reading experience that takes learning to a completely new level.<br><br>Arthrex acknowledges these trends and sees advancements in mobile technology as a great opportunity to redefine the way orthopaedic surgeons can be trained and educated. An eBook task force was formed earlier this year with the goal to develop the company’s next generation digital textbooks that will eventually replace traditional means of education. The talents and skills of Graphic Designers, Medical Illustrators, 3D Animators, Videographers, Multimedia Artists and Software Developers were harnessed in an effort to push the technological and creative envelope of digital publishing to the limit. Nobody knew that the task force was about to change the trajectory of Arthrex’s medical education program forever. &nbsp;<br> <br> <img alt="ArthrexiBooks" class="pull-right" src="" width="250" />When the work of the eBook task force was first displayed at the AAOS meeting in Chicago earlier this year, everyone understood that a new era for product demonstration and surgeon education had arrived. With an iPad and Arthrex’s iBooks, surgeons can now interact with suture anchors in a 3-dimensional environment, zoom in and out of high-resolution images such as x-rays and MRIs, watch surgical technique videos and take notes without ever leaving the eReader application of their tablet. With the touch of a finger readers can experience the mechanics of surgical instruments such as the FlipCutter and understand the sophistication of suture button constructs like the ACL TightRope. Medical device and surgical technique education has never been more engaging and educational at the same time. &nbsp;<br> <span><br>By embracing mobile technology and transitioning from traditional to modern reading formats such as iBooks, Arthrex demonstrates its uncompromising commitment to innovation and education. The creative talents at Arthrex took the company’s mission of “Helping Surgeons Treat Their Patients Better” very seriously when they set out to develop a new education format that would allow engineers, product managers and scientists to tell stories in ways that weren’t possible before. They delivered highly interactive and engaging digital textbooks that teach medical professionals scientific concepts and surgical techniques in a multisensory fashion that will soon become the new standard of teaching.<br></span><br><span><strong>Arthrex interactive iBooks featuring products and techniques are available for download by <u><a target="_blank" rel="nofollow" href="">logging into</a></u></strong>.<em>&nbsp;</em>For instructions on how to download, please see below. <br></span><br><strong>How to download iBooks:</strong> &nbsp; <br><span>iBooks can only be viewed with iOS devices (iPad, iPhone and iPod Touch) and the <a target="_blank" rel="nofollow" href=";uo=4">iBooks App</a> from the Apple App Store. A Wi-Fi connection for downloading the Arthrex iBooks is strongly recommended.</span> &nbsp; <br><br><strong>How to download iBooks from &nbsp; &nbsp;</strong> <br><span><span><br>1.&nbsp;</span>On your iPad, open Safari and log on to</span> <br><span>2.&nbsp;Navigate to the following page: <a target="_blank" rel="nofollow" href=""></a></span> <br>3.&nbsp;Select “iBooks” from the “Resource Type Filter” on the left side. <br>4.&nbsp;Select one of the available links and let Safari download the file (this might take a moment). <br>5.&nbsp;Once the download is complete, select “Open in iBooks” and wait until the iBook opens inside of the iBooks App (this might take a moment). &nbsp;<br> <br><strong>How to download iBooks&nbsp;from a desktop/laptop: &nbsp; &nbsp;</strong> <br><span><span><br>1.&nbsp;</span>On your desktop/laptop log on to</span> <br><span>2.&nbsp;Navigate to the following page: <a target="_blank" rel="nofollow" href=""></a></span> <br>3.&nbsp;Select “iBooks” from the “Resource Type Filter."&nbsp;<br>4.&nbsp;Select one of the available iBooks to initiate the download. <br>5.&nbsp;Once the download has finished, drag the file into iTunes. <br>6.&nbsp;Navigate to iBooks in iTunes, select the Arthrex iBook and&nbsp;drag/drop the iBook to the iPad. Kristin Bartlett Arthrex Releases Univers Revers? Shoulder Arthroplasty System in the United States - First Surgery Successfully Performed in Chillicothe, OH <p> <img alt="Univers_Revers" class="pull-right" src="" style="padding: 7px;" width="250" />Arthrex has released its innovative Univers Revers Shoulder Arthroplasty System in the United States following approval of the system by the U.S. Food and Drug Administration on May 31, 2013. Reverse shoulder replacement surgery was introduced in the United States in 2004, but Arthrex&rsquo;s newly-released system incorporates unique features that further advance arthroplasty implant technology.&nbsp;<br /><br />&ldquo;The recent FDA approval of the Arthrex Univers Revers Shoulder Arthroplasty System is another testimony to Arthrex&rsquo;s continuous innovation in helping surgeons treat their patients better,&rdquo; said Reinhold Schmieding, Arthrex President and Founder. &ldquo;We applaud our creative engineers, tenacious regulatory affairs management and dedicated consulting surgeons worldwide for this significant achievement in orthopaedic surgery.&rdquo;<br /><br />The first U.S. Univers Revers implantation was successfully performed last week by Brian S. Cohen, M.D. (Chillicothe, OH). &ldquo;Having been very involved with the reverse shoulder arthroplasty procedure since its early inception in the United States, and having performed over 700 of the procedures, I had some concerns that a transition to a new system would set back my &ldquo;learning curve,&rdquo; said Dr. Cohen. &ldquo;Fortunately, the new Arthrex Univers Revers System has instrumentation that is surgeon-friendly, and flows seamlessly with the goals of the procedure. My surgical team has been with me for almost 13 years; by our second case, many commented that it looked like we had been using the system for years. &nbsp; &nbsp;<br /><br />Dr. Cohen added, &ldquo;Another big advantage of the Arthrex Univers Revers Shoulder Arthroplasty System is the unique and clinically appropriate features that it offers. The variable neck angle of 135 degrees and 155 degrees allows the surgeon to match the patient&rsquo;s clinically specific issues with an appropriate humeral reconstruction. Also, the geometry and design of the humeral stem allow the surgeon to perform a press fit procedure.&rdquo;<br /><br /> <img alt="Univers_Revers" class="pull-left" src="" style="padding: 7px;" width="315" />Arthrex&rsquo;s Univers Revers Shoulder Arthroplasty System has been utilized in Europe since 2012, with over 500 prostheses implanted to date.<br /><br />To receive additional updates about this and other new product and technique innovations at Arthrex, <a href=";utm_medium=BLOG&amp;utm_content=WNSE+SIGNUP+UNIVERS+ARTICLE&amp;utm_campaign=INBOUND+CAMPAIGNS" target="_blank" rel="nofollow">sign up for the What&rsquo;s New at Arthrex email</a> (surgeons only).</p> Cassandra Engeldinger Arthrex Launches New Corporate Website for Busy Surgeons on the Fly <strong><em></em></strong>Author:&nbsp;<strong>Reinhold Schmieding,&nbsp;<em>President &amp; Founder, Arthrex, Inc.</em></strong><br><br>This fall, Arthrex proudly launches the <a alt="NEW" href="/">NEW</a>&nbsp;in celebration of our three decade contribution to arthroscopic surgery and less invasive orthopaedic innovation based on a single mission of helping surgeons treat their patients better.<br><br>The new will provide an experience like no other within orthopaedics; an evolution of website technology allowing you to search a vast and far reaching amount of orthopaedic knowledge easily and at lightning speed. We designed this site with a global focus that includes multiple language adaptability to meet the needs of&nbsp;the global surgeons and healthcare professionals who work all hours of the day and night in various locations around the world. Whether by mobile phone, tablet or desktop, provides a unique experience in website access and navigation.<br><br>As part of&nbsp;the official campaign launch for the new, please welcome a new addition to the Arthrex website- “OrthoSpeedia,” the Arthrex Dragonfly. Orthospeedia’s artistic design constructed of the latest <img alt="OrthoSpeedia" class="pull-right" src="" width="400" />innovative Arthrex products, embodies our continued commitment to orthopaedic product innovation: past, present and future. The Dragonfly’s speed and sophistication, combined with its unique architecture and maneuverability perfectly represents the essence of the NEW Throughout our website launch campaign, he’ll navigate you through the various features and functionality of our new website, metamorphosing with the latest Arthrex products.<br>&nbsp;<br>At first glance you’ll notice a clean, user-friendly interface. Navigate through Arthrex’s product and procedure catalog like never before with speed, agility and coordinated sophistication. <strong>You’ll gain immediate access – no login required!&nbsp;</strong> The quick sort feature helps you find educational resources, products and related science for specific techniques quickly. Filter by resource type and you’ll gain access to our extensive digital knowledge library containing hundreds of surgical technique animations, illustrated brochures, surgeon newsletters, surgical technique videos and research white papers updated daily.<br>&nbsp;<br>To provide you the best possible search experience, Arthrex partnered with the world’s leading search engine – Google. Bypass the navigational menu items by simply typing what you’re looking for in our search box at the top and everything related to your keyword appears instantaneously and in a format with which you are familiar.<br>&nbsp;<br>Did you speak with a colleague who mentioned an upcoming educational meeting in Naples? The <a href="/calendar" title="Events Calendar">Events Calendar</a> provides information that is up-to-date so you can plan your next hands on surgical skills education experience with our medical education staff, product managers and leading surgeon instructors.<br>&nbsp;<br>Requesting product quotes and surgical evaluations is easy.&nbsp; Review new product information and request a price quote or product evaluation from a representative directly through the site. Getting in touch with us has truly never been easier or more seamless.<br>&nbsp;<br>Finally, stay up to date on all things product-related by visiting our new online <a href="/newsroom">Newsroom</a> and signing up to receive information as it happens via <a href="/account/create-account">email</a>&nbsp;or through one of our <a href="/subscribe" title="RSS">RSS</a>&nbsp;feeds. Our new blog will provide us a chance to communicate with you on issues that we all care about; to help you stay informed on the latest orthopaedic science and&nbsp; industry topics and trends, and to share them with your colleagues.&nbsp; Guest authors will include leading surgeons and professionals who will weigh in on the latest innovations in orthopaedic medicine.&nbsp; Be sure to bookmark this page and/or sign up for updates to keep informed on the latest orthopaedic industry information.<br>&nbsp;<br>Beginning this fall, we’ll connect with each other in ways that were never before possible through state-of-the art education, innovative communications and up-to-date information. We look forward to your feedback about the new site and to advancing our mission of helping surgeons treat their patients better now and into the future.<br><br><br><br><br><br><br> Cassandra Engeldinger 父爱如山动漫全集在线观看_av日本_第一福利在线永久视频