Scottsdale, AZ — February 14, 2012 — Cayenne Medical, Inc., a private sports medicine device company, today announced the closing of a $10 million equity financing, with new investor Fletcher Spaght Ventures joining existing investors Split Rock Partners, MB Venture Partners and Investor Growth Capital. The proceeds will be used to enhance the company’s sales and distribution and to support expansion of its portfolio of sports medicine orthopedic solutions.

Cayenne Medical currently markets products that address previously unmet clinical needs in knee ligament reconstruction and meniscal repair, including the AperFix® II System, the CrossFix® II System and the iFix® System. This month the company is also launching the Quattro™ Shoulder System for rotator cuff and labral repairs.

“We are pleased to support Cayenne Medical and its innovative, complete procedural solutions for common sport-related orthopedic injuries,” said Peter Kleinhenz of Fletcher Spaght. “We believe the Company’s high quality products, coupled with its impressive executive team will enable even further success as it introduces additional novel soft tissue repair solutions to market.”

“Cayenne is privileged to have Fletcher Spaght Ventures join our already strong and committed investor syndicate. We look forward to a year of accelerated company growth, with our new innovative solutions for the shoulder to complement our best-in-class knee products,” said David Springer, President and CEO, Cayenne Medical.

About Cayenne Medical, Inc.:
Based in Scottsdale, Arizona, Cayenne Medical is a privately held medical device company defining new technology for the soft tissue reconstruction segment of the sports medicine market. The company was founded in 2005 and is focused on leading the transformation of traditional soft tissue repair procedures, by applying advanced technology through minimally invasive techniques. For more information, visit www.cayennemedical.com.

About Fletcher Spaght Ventures:
Fletcher Spaght, Inc. was founded in 1983. The firm provides strategy and financing assistance to new ventures, risk capital investors and large enterprises with emerging technologies or other growth opportunities. We develop market research, competitive analysis and financial analysis to advise clients on the commercial potential of new ventures and the options for growing, funding or acquiring new businesses. Fletcher Spaght Ventures invests in high potential companies identified by our practice groups in High Technology, Healthcare and Corporate Growth. For more information, visit www.fletcherspaght.com.

Executives with Cayenne Medical Inc. recently demonstrated the efficacy of good timing when they launched the company’s second generation soft tissue knee repair device during the 2011 American Academy of Orthopaedic Surgeons (AAOS) Annual Meeting in San Diego, Calif.

The AperFix II system for multi-ligament repairs of the knee improves upon Cayenne’s AperFix ligament reconstruction technology, which utilizes a single tunnel, all-inside approach for attaching the soft tissue graft at the aperture of the femoral and tibial tunnels. The technique—approved by the U.S. Food and Drug Administration in 2007—creates a shorter, stiffer and more anatomic ligament repair. Since its debut four years ago, the company’s technique has been validated by several studies, including a Harvard clinical analysis published in March 2009 which found that Cayenne’s AperFix reconstruction technique better resembled the natural intact anterior cruciate ligament (ACL) when compared to more common, single-bundle techniques.

The AperFix II introduces a Cannulated Tibial System to the original AperFix technique, providing surgeons with an easier insertion method and standardized positioning of the implant. In ACL repairs, the next-generation system allows for the rotation of two tendons representing the anteromedial and posterolateral bundles to more accurately match the positioning of the native ACL bundles. New enhancements to the femoral device also make it easier for surgeons to insert and place the graft within the tunnel.

“The AperFix II System offers a simple and efficient technique to obtain consistent circumferential graft compression, restoring native knee kinematics,” noted Kenneth Montgomery, M.D., an orthopedic surgeon with Morristown, N.J.-based Tri-County Orthopaedic & Sports Medicine Inc. “I believe this procedural enhancement will ensure the integrity and strength of the reconstructed ligament, providing patients with a more stable knee.”

More stable knees isn’t the only benefit of the AperFix II system. Executives told Orthopedic Design & Technology that the device can help patients with ACL injuries recover faster, which can be a godsend for amateur athletes and weekend warriors anxious to return to the playing fields (or courts). Patients also don’t have to worry about revision surgeries when undergoing an ACL procedure using the AperFix system (the original)—the device has a significantly lower revision rate than other ACL repair products and methods. Timothy S. Nash, vice president of marketing for the Scottsdale, Ariz.-based firm, estimated the revision surgery rate for patients treated with the AperFix system to be less than 1 percent; revision surgery rates for other ACL repair devices range from 7 percent to 12 percent, he said.

“As the industry continues to lean in favor of soft tissue ligament reconstruction, we have seen much success with our flagship product AperFix and an increasing interest in its anatomic repair through aperture graft fixation,” said James W. Hart, Cayenne Medical’s executive chairman. “The enhancements we’ve made to the tibial portion of the procedure with AperFix II are in line with this trend and affirm our commitment to evolving our technology platform for the benefit of surgeons and their patients.”

The AperFix II Cannulated Tibial System is comprised of the tibial implant made from PEEK (Polyether ether keytone) polymer, a tendon expander, a guidewire, a cannulated screw and a driver pre-loaded with tibial sheaths and a sheath holder.

Founded in 2005, Cayenne Medical is a privately held company that develops soft tissue reconstruction technology and devices for the sports medicine market.

Scottsdale, AZ — June 29, 2011 — Cayenne Medical, Inc., a private sports medicine device company, announces the launch of CrossFix® II Meniscal Repair System, its second generation device for treatment of traumatic meniscal tears. CrossFix® II will be on display at the 2011 American Orthopaedic Society for Sports Medicine Annual Meeting, July 7-10 in San Diego, CA.

Tal David, MD, orthopedic sports medicine specialist, San Diego, CA, commented, “The design enhancements for CrossFix II serve to improve the integrity and strength of the meniscal repair, which I expect to have a positive impact on patient outcomes. The fast, simple and easily reproducible repair technique adds to the efficiency of the procedure in the operating room.”

The CrossFix® II platform offers a unique minimally invasive, all-suture meniscal repair that reduces the risk of chondral injury associated with other implantable meniscal devices. Its “all-inside” technique uses suture delivery needles, available in both curved and straight designs, inserted through a single incision to gain access to multiple tear sites from the inside surface of the meniscus. The simple procedure, which can be performed in minutes using the Company’s proprietary instantaneous mattress stitch and pre-tied, sliding Hot Knot™, replicates the repair of standard open suturing techniques.

The enhanced CrossFix® II now includes sharper, stiffer suture delivery needles, which have inspired a simpler technique for needle insertion into the joint space and the meniscus. CrossFix® II also features an improvement in suture strength resulting in a high strength biomechanical repair.

David Springer, CEO of Cayenne Medical, said, “Evolving our already best-in-class meniscal repair technology to further enhance performance and cater to specific surgeon needs represents Cayenne Medical’s commitment to providing innovative solutions for the sports medicine market. We fully expect CrossFix II to be as well received as our second generation soft tissue knee ligament reconstruction device, AperFix II, launched only a few months ago.”

CrossFix® II is now commercially available in the U.S. The new needle insertion technique will be demonstrated at the Cayenne Medical AOSSM Booth (#815) and field training is available upon request.

About Cayenne Medical, Inc.:

Based in Scottsdale, Arizona, Cayenne Medical is a privately held medical device company defining new technology for the soft tissue reconstruction segment of the sports medicine market. Cayenne Medical also currently offers products that address previously unmet clinical needs in knee ligament reconstruction, including the AperFix® II System and iFix® System. The company was founded in 2005 and is focused on leading the transformation of traditional arthroscopic procedures, by applying advanced technology through minimally invasive techniques.

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David Springer, CEO of Cayenne Medical, said, “Through this strategic partnership with Parametrics Medical, Cayenne now offers surgeons a comprehensive menu of safe and effective allograft options that compliment Cayenne’s best in class knee implant solutions. The Cayenne Medical sales force will have the unique capability to provide for all of their surgeons’ allograft needs regardless of processing preference, graft type or graft specifications.”

Surgeons utilize allografts in knee ligament reconstruction procedures approximately 40 percent of the time due to preference or specific anatomical requirements. This new alliance will allow Cayenne Medical sales representatives to cater to the specific graft needs of the surgeon, whether he or she is performing a bone?patellar tendon?bone ACL reconstruction using the iFix® PEEK Interference System or a soft tissue allograft reconstruction using Cayenne’s flagship AperFix II® System. The highly trained and clinically?minded staff at Parametrics Medical, combined with the procedure specific expertise and superior implant technology provided by the Cayenne Medical sales force, will deliver an unparalleled blend of service, quality and choice.

“We are pleased to be working with Cayenne Medical to partner our high quality allograft service with their innovative knee ligament repair systems. This relationship is highly synergistic, providing surgeons with the optimal tools and technologies to fit the specific needs of their patients,” said Dan Leary, Vice President and General Manager of Parametrics Medical.

Parametrics Medical, with regional offices in Kalamazoo, MI and Austin, TX, has national contracts with several tissue banking resources throughout the United States that are certified by the American Association of Tissue Banks (AATB) and registered with the Food and Drug Administration (FDA). They offer irradiated grafts, non?irradiated grafts, SuperCritical CO2 non?irradiated grafts, as well as various other bone allografts including freeze?dried, frozen, fresh, and cryopreserved.

Cayenne Medical currently offers products that address previously unmet clinical needs in knee ligament reconstruction and meniscal repair, including the AperFix II® System, CrossFix II® Meniscal Repair System and iFix® System. For more information about Cayenne Medical, please visit www.cayennemedical.com.

About Parametrics Medical, LLC:

Parametrics Medical serves the orthopedic community by providing the very best customer service and the most current technologies in allograft bone and tissue, spanning all specialties within orthopedics to include sports medicine, trauma, reconstructive and spine. By working with reputable tissue banking resources throughout the country, Parametrics Medical’s Preferred Tissue Services is able to provide surgeons with allografts processed and sized to their specifications at a fill rate of nearly 100% with the guaranteed regulation provided by the American Association of Tissue Banks (AATB) and the Food and Drug Administration (FDA). For more information, visit www.parametricsmedical.com.

About Cayenne Medical, Inc.:

Based in Scottsdale, Arizona, Cayenne Medical is a privately held medical device company defining new technology for the soft tissue reconstruction segment of the sports medicine market. The company was founded in 2005 and is focused on leading the transformation of traditional arthroscopic procedures, by applying advanced technology through minimally invasive techniques. For more information, visit www.cayennemedical.com.

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Scottsdale, AZ —June 1, 2011 — Cayenne Medical, Inc., a private sports medicine device company specializing in the soft tissue reconstruction segment, announced the appointment of Dev K. Mishra, M.D., as Medical Director. In this new role, Dr. Mishra will provide expert counsel in the areas of medical education and clinical research activities, mainly focusing on the development of new products and the design of clinical protocols and procedures.

Dr. Mishra, 49, is Board Certified in Orthopaedic Surgery and Orthopaedic Sports Medicine, with over 16 years experience specializing in the treatment of shoulder, elbow, knee and ankle disorders. He currently advises several venture capital firms, including SV LifeSciences, Onset Ventures, The Innovation Factory and Intersect Partners, and holds the positions of Chief Medical Officer at AlterG, Inc. and President of Sideline Sports Doc, LLC. He has previously served as a Medical Officer at Oratec Interventions, Inc., MedModus, Inc., and as Clinical Advisor to Stryker Endoscopy.

David Springer, CEO of Cayenne Medical, said, “Dr. Mishra is an important addition to the Cayenne management team as we move into our next stage of growth and development. He has an impressive background advising several emerging medical technology companies on product development and clinical study design, and his extensive clinical experience and commitment to sports medicine will be invaluable as we continue to develop innovative solutions to fulfill the unmet needs of surgeons and their patients.”

In addition to his clinical and corporate accomplishments, Dr. Mishra is a fellow of the American Academy of Orthopaedic Surgeons and American Orthopedic Society for Sports Medicine. Since 1995, he has served as a Team Physician for the University of California, Berkeley, and has been an orthopaedic consultant to the U.S. Soccer Federation, and the California Victory professional soccer teams.

Dr. Mishra received his medical degree from the University of California, San Diego, where he also pursued his residency in orthopaedic surgery. While at UCSD, he received the Zimmer/AOA Resident Award for his research on exercise induced muscle injury, and completed a fellowship in Orthopaedic Research. Following residency, Dr. Mishra completed a fellowship in Sports Medicine at the University of California, San Francisco. Dr. Mishra is an undergraduate alumnus of Yale University.

Cayenne Medical currently offers products that address previously unmet clinical needs in knee ligament reconstruction and meniscal repair, including the AperFix II® System, CrossFix® Meniscal Repair System and iFix® System. For more information Cayenne Medical, please visit www.cayennemedical.com.

About Cayenne Medical, Inc.:

Based in Scottsdale, Arizona, Cayenne Medical is a privately held medical device company defining new technology for the soft tissue reconstruction segment of the sports medicine market. The company was founded in 2005 and is focused on leading the transformation of traditional arthroscopic procedures, by applying advanced technology through minimally invasive techniques. For more information, visit www.cayennemedical.com.

Downloadable PDF

“I was coming down from a rebound; there was no contact or anything,” she said. “It just tore. I immediately fell to the ground. It was the worst pain of my life.”

It happened during a summer league basketball game. She damaged her ACL and her meniscus — part of the connective mechanism that helps the knee operate.

It was July 2009. She was about to enter her senior year playing basketball and volleyball for Marquette High School. She also played other sports year round, so the thought of being benched was horrible.

“I was in shock,” she said. “I never thought about it being torn.

“The first thing I asked my doctor, was I going to be able to play again, my senior year, that was my biggest concern.”

The history of what ACL injuries do to athletic careers, pro and amateur, has been pretty bleak. Athletes routinely are sidelined several months or even permanently. New England Patriots quarterback Tom Brady missed most of the 2008 NFL season with an ACL injury.

“The surgery used to leave a 10-inch gash along the side of the leg, days in the hospital, then a cast for two months,” said Dr. Michael Milne, the orthopedic surgeon and sports medicine physician who helped Potthast. Six to eight months later an athlete might continue playing, he said.

It was no comfort to Potthast to learn that women athletes are up to four times more likely than men to suffer ACL injuries.

There’s plenty of speculation as to why, Milne said.

Women start training later for sports, women’s joint physiology isn’t as compatible with impact sports as men’s, hormones, skill, but no one really knows, he said.

What is known is that basketball, volleyball and soccer, in that order, account for the most ACL injuries among women athletes, and 80 percent don’t involve contact — just landing the wrong way or taking a step at the wrong angle, he said.

Potthast wanted to be ready for basketball tryouts at the first of the school year and be ready to play in October.

She consented to a relatively new type of surgery that involved small holes in her knee and a fast recovery time.

October arrived and the 6-foot forward returned to the court to finish her high school career.

“It was like nothing had happened,” she said. “Even the scar was so small you could hardly see it. I’m a girl and the scar really mattered.”

Potthast’s surgery was a procedure called the AperFix System.

BY HARRY JACKSON JR. • harry.jackson@post-dispatch.com > 314-340-8234

Cayenne Medical Inc., on the northeastern corner of 92nd Street and Bahia Drive, develops and sells products used in knee ligament and muscle repair. The milestone was announced recently at meeting of the Arthroscopy Association of North America.

“I think we’ve earned a lot of respect in the industry in that we’ve built some good products and we’ve worked hard to grow a customer base of around 400 surgeons across the United States,” said James Hart, president and CEO. “Even though we have a small market share overall because there’s 400,000 procedures done annually . . . in certain cities we’ve demonstrated a 20 to 25 percent market share.”

Hart, who founded the company in 2005, had a background in the sports-medicine device industry. Starting the company required a substantial investment up front for product development.

Cayenne’s flagship product is AperFix, which Hart says is a stronger, less-invasive device for soft-tissue multiligament repairs in the knee. First implanted in the United States three years ago, the AperFix technology has been used by more than 1,300 surgeons in 20 countries.

“We pretty much worked on developing our concept for AperFix for the first two years,” Hart said. “When I say we developed it out, I mean designs, prototyping the designs, strength-testing the designs and then putting them in doctors’ hands and letting them try the product on human cadavers, which is very common protocol in the medical-device industry.”

Cayenne’s clients are orthopedic surgeons, some of whom have been associated with the company since its inception or earlier.

Dr. Douglas Freedberg, an orthopedic surgeon with Arizona Sports Medicine Center, has used AperFix in numerous surgeries. His client base includes everyone from “weekend warriors” and teenagers to professional athletes with the Arizona Cardinals and Phoenix Coyotes.

“You want ideally as many people as you can to return to as active a lifestyle as they desire, and this is something that has helped us along the way,” he said. “This is another building block that gets the patients back to an active lifestyle. For many of them, their goal is ‘I want to get back to what I love to do, get back to life.’ ”

The company has 32 employees at its Scottsdale headquarters and 42 employees overall. Product design, research and development, engineering, quality systems, accounting and finance, customer service and marketing functions take place in the Scottsdale office.

“Our regional offices are sales operations,” Hart said. “Because we are still a small company, we have our manufacturing outsourced at a number of different locations.”

Because of continuing investment, Cayenne has yet to earn a profit, but Hart hopes that’s no longer the case by 2012.

“We should be at a break-even financially and able to support our growth by ourselves going forward,” he said. “When we get to that break-even point . . . there’s no reason we can’t grow the company to be a larger force in the industry.”

The company survived the recession while many other startups in the industry failed, Hart said.

“It just shows that we really built good products, have a strong management team and have gotten the product in front of the right physicians,” he said.

Scottsdale, AZ —November 18, 2010 — Cayenne Medical, Inc., a private sports medicine device company, annaounces that it has reached its 50,000 implant milestone.  Specializing in the soft tissue segment, Cayenne currently offers products that address previously unmet clinical needs in knee ligament reconstruction and meniscal repair, including the AperFix® System, CrossFix™ Meniscal Repair System and iFix® System.  The announcement was made today at the Arthroscopy Association of North America (AANA) 29th Fall Course in Phoenix, AZ.

“Our 50,000th implant represents an important milestone for Cayenne as it affirms the company’s commitment to transform the soft tissue reconstruction segment and is proof-positive that our technology platform continues to gain significant traction throughout the orthopedic industry,” said James W. Hart, President and CEO of Cayenne Medical. “We plan to continue providing innovative sports medicine solutions that offer ease-of-use for physicians and improve quality of life for patients looking to continue their active lifestyles.”

The company’s flagship product AperFix is a stronger, less invasive femoral and tibial fixation device for soft tissue multi-ligament repair, including the most common anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) tears. First implanted in the United States three years ago, the AperFix technology has been used by more than 1,300 surgeons in 20 countries.

The AperFix single tunnel, all-inside surgical technique attaches a soft tissue graft at the aperture (opening) of the femoral and tibial tunnels created for fixation. This creates a shorter, stiffer and more anatomic ligament reconstruction that is designed to restore natural knee kinematics.  For ACL reconstruction, the technically less-demanding procedure can be performed using a traditional tibial approach or a more anatomical approach through the anteromedial portal.

“Cayenne Medical’s innovative suite of products has allowed me to provide patients at all activity levels with strong, reliable and less invasive knee repair,” said Tal David, MD “The versatility of the AperFix system in particular has allowed me to confidently perform multiple ligament reconstructions with ease.”

The CrossFix system, launched in 2009, is a fast, efficient device used to treat repairable traumatic meniscal tears. It provides a suture-only repair that replicates the strength of “gold standard” open surgical stitching through a much less invasive, all-inside, single incision procedure.

The iFix system, launched in 2008, was developed for surgeons who practice the bone -tendon-bone ACL reconstruction technique, as opposed to the soft tissue technique used with AperFix. iFix is the first FDA-approved interference screw manufactured using polyetheretherketone (PEEK™), a form of plastic which is highly biocompatible, biomechanically strong and radiolucent.

ACL injuries are one of the most common sports-related injuries, with nearly 400,000 procedures conducted in the United States each year. Meniscal tears, also referred to as cartilage tears, are among the most common knee injuries, with more than 800,000 procedures and 300,000 repairs performed each year.

For more information about AperFix, CrossFix or iFix, visit www.cayennemedical.com. For information on the latest trends in sports medicine, visit the Cayenne Medical Blog at www.cayennemedical.com/blog.

About Cayenne Medical, Inc.:
Based in Scottsdale, Arizona, Cayenne Medical is a privately held medical device company defining new technology for the soft tissue reconstruction segment of the sports medicine market. The company was founded in 2005 and is focused on leading the transformation of traditional ACL, PCL and meniscal repair procedures, by applying advanced technology through minimally invasive techniques. For more information, visit www.cayennemedical.com.

Meniscal repair indications have not really changed in recent years. Typically younger, more active patients with concomitant ACL reconstruction and peripheral-third vertical tears continue to be the “best” repair candidates. However, even in these “ideal” candidates, meniscal repair continues to represent a significant challenge. While most will not dispute that vertical tears greater than 1 cm in the peripheral-third of the meniscus should be repaired, there has been new attention on repairing posterior root tears. With these root tear repairs, an inside-out repair is not feasible due to the posterior midline placement of the needles and the passage of the suture.

Strength of meniscal repair

There has been a significant change in meniscal repair technique in the last few years. While inside-out vertical mattress repair is the gold standard, an all-inside vertical mattress repair pattern is becoming more common. Studies performed within the last 2 to 3 years have shown equal pull-out strength between all-inside and inside-out repair techniques, without the extra incisions and morbidity of inside-out repair. Barber and colleagues in 2009 showed that the newer all-inside suture devices have equal or greater pull-out strength and cyclic load to failure strength compared with suture-only repairs like in an inside-out repair. However, in an earlier study in 2000, Barber also showed that a double-vertical suture-only construct was statistically stronger than any of the implants — although, the article is 10 years old, and many newer generations of all-inside meniscal repairs have emerged with newer suture material.

In a brief discussion of the two articles, the double vertical meniscal repair tested in 2000 used 2-0 Mersilene sutures and had a pull-out strength of 113 N. In the article from 2009, the suture tested was mostly no. 0 ultrahigh molecular weight polyethylene (UHMWPE) suture, which had 109 N to 124 N pull-out strengths. Given that, a viable fixation option is to fix vertical meniscal tears with all-inside, suture-only devices in a double vertical pattern with UHMWPE suture. This particular method will help avoid gapping on the tibial surface that can be seen with vertical mattress sutures placed only on the superior surface of the meniscus. The suture-only meniscal repair can also reduce any vascular, nervous or soft tissue entrapment that can be seen with meniscal repair implants.

There have been numerous studies to show the higher occurrence of lateral compared to medial meniscus tears with acute ACL rupture. While there has been extensive literature to favor repairing vertical peripheral tears, a slightly different tear representing a more significant challenge is the posterior lateral meniscal root tear (Figures 1, 2).

Arthroscopic view of the left knee posterior lateral meniscus root tear, which goes greater than 50 % of the root.Image: Nord KD

Left knee posterior lateral meniscus root tear involving more than 50% of the root.Image: Cayenne Medical, Inc.

The increase in difficulty lies not in the diagnosis, but the care of these tears. Simple meniscectomy for small radial tears on the free edge of the meniscus is not being argued, but rather radial tears that extend greater than 50% of the meniscus pose a significant problem. Performing a partial meniscectomy of the root tear can destabilize the entire meniscus and lead to further mechanical symptoms or early onset osteoarthritis. Inside-out fixation of a root tear is not feasible, and all-inside techniques do not restore the anatomy, which is a meniscus anchored to the posterior central tibia plateau. With conventional all inside suture techniques, the root would no longer be anchored to the tibia, but rather to the posterior capsule.

The following is a new technique for posterior lateral meniscal root tears/avulsions using a suture-only meniscal device, passing the sutures through a bone tunnel and tying over a button on the tibial cortex. This technique is also applicable to medial meniscal root tears.

All-suture meniscal repair

CrossFix Animation

The rationale for this device is to simplify suture passage and eliminate the need for more cumbersome suture-passing or shuttling device(s). This particular device passes two simultaneous needles through the meniscus, and then has a suture grabber that grabs one end and pulls the strand into the other needle, thus throwing the suture completely behind and around the meniscus and capsule. When you remove the device, there is a pre-tied Weston knot that slides down into position and can be tensioned with a knot pusher. Two half-hitches can be added if desired.

The premise for this technique stems from recent article by Harner and colleagues repairing medial meniscal root tears over a bone tunnel. The difference in this article is this technique encompasses passing an all suture fixation in a 90-90 pattern with a different meniscal repair device, as opposed to a utilizing a suture passer. The suture is then brought out through a bone tunnel and tied over a button.

If there are any concomitant procedures to be done, then they must be addressed first. In the figures shown on page 12, there was a concomitant ACL disruption and if there is one present, we recommend first drilling both the femoral and tibial tunnels; however, do not pass the ACL graft before drilling the meniscal bone tunnel or prior to passing the sutures through the meniscus. This technique article will not discuss the steps performed in ACL reconstruction, as that is beyond the scope of this article.

Shown is the 90-90 technique. A horizontal mattress pattern is placed with the CrossFix (Cayenne Medical Inc.) followed by a second vertical mattress suture to give two pairs of suture 90° to each other.Images: Cayenne Medical, Inc.; Nord KD

Capturing the meniscal root

Once the other pathology has been addressed, a tunnel is drilled at the meniscal root insertion utilizing an ACL drill guide (Figure 3). Ideally, from a line-of-sight perspective, the bone tunnel should be drilled from the medial tibia parallel to an ACL tibial tunnel, as it would be for a medial root tear. However, since in this case there was a concomitant ACL reconstruction being performed also, the bone tunnel was taken from just lateral to the tibial tubercle to avoid any tunnel encroachment. The size of the tunnel does not need to be large, only a 5- or 6-mm tunnel. After the tunnel is drilled, then using an all-inside suture only meniscal repair device, CrossFix (Cayenne Medical Inc.), the posterior horn of the lateral meniscus is “captured” with the suture in a 90-90 fashion, giving a Mason-Allen-like suture configuration. With this particular meniscal repair device, there are dual prongs of the device that pass the suture simultaneously through the meniscus. There is a Weston knot built in to the device, and this is automatically passed when the device is fired, and the knot is advanced when the device is withdrawn. By passing one suture in a horizontal mattress fashion, then one in a vertical mattress fashion, there is 90-90 fixation through the meniscus (Figure 4). Next, a suture retriever is fed through the bone tunnel, the suture ends are retrieved and pulled distally out of the bone tunnel (Figure 5).

The ACL graft (or other ligaments being repaired) can then be passed, tensioned, and fixed. The last step will be to tie the posterior horn sutures over a button because the hyperflexion needed for ACL drilling and the cyclic tensioning can stress the no. 0 suture, and breakage can occur. Once any ligamentous reconstruction has been completed, then the sutures can be tied over a button on the tibial cortex with the knee in flexion. We recommend tying the respective sutures from each pair together, but also taking a suture from each pair and tying it to a suture from the other pair — if suture AA is tied, and BB is tied, then take a suture A and suture B and tie them together giving two AB knots also over the button (Figure 6).

Suture retriever passed through bone tunnel to retrieve sutures.Image: Cayenne Medical, Inc.

Anatomic meniscal root restoration

A significant advantage to this technique is anatomic restoration of the root to the tibial surface, as well as significant bony bleeding from the ACL reconstruction and the bone tunnel drilled for the meniscus. This results in significant healing factors in the joint available for healing of the meniscus and healing of the bone to the meniscal root.

We recommend limiting rehabilitation to partial weight-bearing with a hinged knee brace locked in extension, and no flexion greater than 90° for 4 weeks. After 4 weeks, the patient and therapist can resume ACL rehab as outlined by the respective surgeon.

In summary, this is a new technique for posterior horn lateral meniscal root tears using the CrossFix meniscal repair system, a suture-only meniscal repair device and tying the sutures through a bone tunnel over a button. We feel that this particular repair technique better restores the meniscal anatomy than previous all-inside repairs, and avoids the neurovascular structures at risk during an inside-out repair.

References:

• Barber FA, Herbert MA. Meniscal repair devices. Arthroscopy 2000;16:613-618.
• Barber FA, Herbert MA, Schroeder FA, Aziz-Jacobo J, Sutker MJ. Biomechanical Testing of New Meniscal Repair Techniques Containing Ultra High–Molecular Weight Polyethylene Suture. Arthroscopy. 2009; 25:959-967.
• Harner CD, Mauro CS, Lesniak BP, Romanowski JR. Biomechanical consequences of a tear of the posterior root of the medial meniscus. Surgical technique. J Bone Joint Surg (Am). 2009;91:Suppl 2:257-70.

• Keith D. Nord, MD, MS, can be reached at Sports, Orthopedics & Spine, 569 Skyline Dr. Suite 100, Jackson, TN, 38301; 731-427-7888 or 888-SPORTDR; e-mail: shoulderdrnord@yahoo.com. He has received an honorarium from Cayenne Medical for teaching.

In the past year, the three-sport athlete has had surgeries to reconstruct the torn anterior cruciate ligament (ACL) in both knees.

“The first time I was going ‘Why me? Why me?’” Familo said. “The second time I was going ‘Why did this happen to me again, of all people?’”

Despite her incredible bad luck, Familo had one thing on her side. She was treated by a doctor proficient in an advanced surgical procedure called AperFix.

AperFix Animation on YouTube

The system provides patients with a stronger, safer, and less invasive fixation device for soft tissue multi-ligament repair, including ACL reconstruction.

“It’s an easier operation with better fixation and better healing,” said Dr. Glenn Axelrod, an orthopedic surgeon who performed both of Familo’s knee surgeries.

Aperture fixation allows for a shorter, stiffer ligament graft to be created that is more similar to the natural ACL, which may increase knee stability.

Dr. Axelrod said he has done more than 100 surgeries in the past couple of years using the AperFix procedure. “I became increasingly happier with the results,” he said. “I use it essentially exclusively now.”

Using a soft tissue graft from the patient’s hamstring tendon has replaced the bone-tendon-bone autograft.

“At first, they didn’t think it was as good a graft. High-level athletes were getting bone-tendon-bone,” Dr. Axelrod said.

Now, results have proven differently.

“It fixes the tendon very close to the entrance of the bone tunnels,” Dr. Axelrod said. “It’s a stiffer graft and it’s better healing.”

The daughter of Don and Theresa Familo, Samantha, 15, said both knees are coming along nicely.

“Hopefully I’ll be ready for softball season,” she said.

For the rest of the story, see Tuesday’s ( November 9, 2010) edition of The Palladium-Times.

By MIKE LEBOEUF
Published Online: Monday, November 8, 2010