Alright guys, we've got lunch is going to be ready around 12.15 to 12.30. So we're going to have two more demos this morning. This one's going to be Team Fabricant from New York and Veng Yen from Boston. The first one's going to be a fixation tips and pearls for fixation of a tibial spine and tibial eminence fracture, Beng and Pete, can you guys hear me? Yeah, I can hear you. We can hear you. Alright, tell us how to do it. 10 feet away. Oh, he's all the way across the thing. He's across the room. Alright, so this is a tibial spine fracture that we tried to create and you can see that if we reduce it, you know, there's the ACL, so we've reduced the tibial spine. Now you can do this without a perfect reduction or you can, what you can do is you can put a K-wire to temporarily hold it in place. Do we have a K-wire? Do we have a K-wire? We have a big wire. Alright, well forget it then. We'll show them how to use the sutures to reduce it. Okay, so instead we'll indirectly reduce the tibial spine fracture using sutures. So the first thing we'll do is, you know, you want to make sure that the meniscus isn't entrapped, the inner meniscus ligament isn't entrapped. If they are, you can use it, you can pull them out of the way and get this provisionally reduced. So there's our provisional reduction and then the next thing that we'll do is, I'll use an ACL aimer, an ACL guide and with the ACL, I set one at 55 degrees and I set one at like 50 degrees because we're going to use this over a bone tunnel. I just, just pretend that goes, yeah, we're good, alright. So the first thing we'll do is we'll drill one. So there's one drill right there, I'm going to go ahead and get the other one set up. I'll reset this to about 50 degrees and I'm going to come on the lateral or the medial side. So this patient had a previous meniscal transplant. An LET and a bunch of other things. And a bunch of other stuff and they got back to sports and then had a tibial spine fracture. So Ben, just to be clear, you put that guide on the outside, outside of the bed or the fracture site? Correct. On the bed of, on the medial side of the bed and the lateral side of the bed. So there's our, there's our suture, or there's our, there's our wire. And again, what will happen is if this is reduced, which I'll re-reduce, you can see it's in the bed, there's one on the medial side and one on the lateral side. This hole is so big, it's just, it's ridiculous. So there's our reduction. Okay. And now what we'll do is we will pass these Houston suture passers. So this is known as a double Houston suture passer technique. All right. Ready? You want to remove this and then I'll fill the Houston up? This one first? Yeah. So what we do is we remove the, the guide, the, the beef pin. As we remove it, we insert the Houston suture passer. And what I want is I want the loop inside the joint. So I've got one rabbit ear inside the joint. Okay. Now we're going to take out the other Houston suture passer, or the other guide wire. Let me just extend the knee. Yep. Go ahead. Now we have the other Houston suture passer inside the knee. So now we have the, the loop, just a little bit, so you can see we got one loop here. We've got the other loop here. Yeah. Come out a little bit. Fractures there. There you go. Okay. So you've got the, the double Houston suture passers within the knee. Next what we'll do is we'll take a suture lasso. And I'm going to insert the suture lasso into the medial portal. And what I'll do is I'll go through this suture, the Houston suture passer, past this, Can I reduce the ACL for you? Yeah, for sure. Pass it through the body of the ACL. And I want this to come out the other side. Making this look very not slick. It's okay. I'm going to, I want to pass this suture that's through this fiber wire through this limb here. So, Ben, can you just give us, give the viewers the tip and trick on how we're working with two instruments and the camera? So, what we've done is we've actually created a trans-patellar portal to help with the passage of the suture. So, now what we have is we have the suture through this loop, Houston suture passer, this Houston suture passer on this side, and we have it through the ACL, and then we have it through the other loop. So, you can see that this is through this loop, and then this one's through this loop, okay? Yeah, number two, and we usually generally pass two sutures. I'm going to go through this side, DCACL, pass this through the front. And so, what are you typically using for your sutures? Are you using absorbable, non-absorbable? It doesn't matter. I mean, I have used both. I generally use non-absorbables. So, if you can understand what we have is we have two sutures now going through that loop, two sutures now going through this loop. And so, what we can do now is we can pull these Houston suture passers, which will bring these two sutures through this side. He will hold on to the sutures that come from here. And then he'll pull the other ones to the other side. Now, we're looped around the... Can you give a little slide here? There we go, perfect. Okay, so now we have our suture construct through the ACL, and it's now they're down through the tunnels. Essentially as I pull on this, you've got reduction of the fragment, and you've got tension on the ACL. And so this is a the reduction of the tibial spine fracture, and then on the outside, you can see that we have a bone bridge between these two, and if we can zoom in on this bone bridge right here. So this is where our sutures are coming out. I'm gonna extend the knee so people can see. So you can see where the sutures are coming out, and then what you can do then is I have a blue suture, I have a white suture, and I can go ahead and sequentially tie them. And while he's tying the, yeah, go ahead. While I'm tying them, he will hold tension on the other two sutures. And while you're doing that, do you have a preferred suture passer that you use so they know they come in different angles? I use a 45 degree suture lasso or suture passer, and I like it I like it in the opposite, on the opposite side as the knee that we're doing. If we're doing a left knee, I'll use a 45 degree to the right. If we're doing a right knee, I'll use a 45 degree to the left. And that's just to make it easier to pass through those windows. So the tibial spine is now tied down, and then you can back this up with a push lock device or something on the rest of the tibia. And what we've done is we've then now reduced our tibial spine fracture, you've gotten tension on our ACL, and the patient has full range of motion of their knee. Ben, just a couple questions to follow up. That was a great demonstration. I appreciate it. Do you, do you recommend or use fluoroscopy? So, I do not. I think that it, you know, what you're looking for is you're looking for, you know, what you're doing is you're, you're getting an indirect reduction of that fracture. If you use fluoroscopy, it may not look as good as you want it to, and you maybe end up, you end up sort of chasing an x-ray and not actually helping the patient. You know, there are times where that anterior part sort of kicks up a little bit. And as long as the patient is stable and has full range of motion of their knee, I'm not super worried about a perfect anatomic reduction. Okay. I mean, it's almost better to have anatomic reduction. It'll make you look better, but I don't get fluoro in the, in the OR, because you're looking at the fracture site. Got it. And, and obviously, that was a suture technique. There's also screw techniques that are available for you guys on your presentations that's online available for you guys. So, this is just one of a couple techniques that can be used. So, I encourage you guys to look at both of them. And thanks, Bang and Pete. I appreciate it. We are just gonna switch the microphones around right now for the last demonstration this morning, which is Ted Gamley from CHOP. His, his technique for lateral articular tenodesis. A few, a few things that you guys are wrapping up this morning. When you're done, go, please go have lunch. Don't forget to hang your gown, hang your gown up, so we can reuse those. And then remove everything before you leave the room. We are gonna go over some cases. Again, a little bit relaxed. Just talk about some cases during lunch. So, we'll just regroup together. If you, can all the instructors at the end of this demo come to the front of this room, so we could just regroup before the afternoon? And if anyone has any questions, comments, concerns, anything that we can do to make your experience better here this afternoon, please grab me at lunch, or Pete, or Kevin, so that we can address them and be sure that you guys are having a good experience. Thank you.

tibial spine fracture

suture fixation

double Houston suture passer technique

ACL guide

push lock device