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Die Naht des vorderen Kreuzbands (ACL) bedeutet die Refixierung des ACL bei einem Ausriss aus dem Femur. Bei augmentierten Kreuzbandnähten können auch ein autologes Transplantat oder Allograft-Gewebe zur Anwendung kommen. Dieser Eingriff wird arthroskopisch durchgeführt und beinhaltet das Nähen des verbliebenen ACL und die Refixierung am vorhandenen femoralen ACL-Ansatz. Das Verfahren beinhaltet das Anlegen von Bohrkanälen in Femur und Tibia für den Transplantatdurchzug. Dank unserer langjährigen Erfahrung und konstanten Innovation im Bereich der Knierekonstruktion haben wir mit der Entwicklung von neuen Technologien zur augmentierten Bandnaht das nächste Kapitel in der Kniechirurgie aufgeschlagen. Bei dieser Arthrex Kreuzbandnahttechnik werden die neuesten Produkte für Bandrekonstruktionen wie SwiveLock®-Anker, FlipCutter®-Fräsen, FiberTape®-Fäden und ACL-Weichgewebetransplantatfixierung verwendet. Weitere Informationen zu diesen Produkten und Techniken finden Sie unter dem Reiter Informationsmaterialien.

This animation demonstrates the technique for primary ACL repair using the ACL Repair TightRope® implant and FiberRing™ sutures.

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ACL Repair TightRope® Surgical Technique Animation

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

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

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ACL Preservation With the ACL Repair TightRope® Implant

Over the past decade, there has been a renewed interest in primary repair as a potential treatment for certain patterns of ACL rupture. The SwiveLock® ACL Repair Kit is the first comprehensive implant system designed to repair and internally brace the ACL. In biomechanical testing, this repair technique has been shown to provide comparable knee stability to ACL reconstruction techniques with bone-patellar tendon-bone (BTB) autografts.&amp;sup1; Clinically, remnant-preserving ACL surgery has shown encouraging outcomes with a higher potential for early healing and better functional outcomes compared to reconstruction surgery.2,3
References
1. Chahla J, Nelson T, Dallo I, et al. Anterior cruciate ligament repair versus reconstruction: a kinematic analysis. Knee. 2020;27(2):334-340. doi:10.1016/j.knee.2019.10.020
2. van der List JP, Jonkergouw A, DiFelice GS. Failure and reoperation rates following arthroscopic primary repair versus reconstruction of the anterior cruciate ligament. Orthop J Sports Med. 2019;7(7 suppl5):2325967119S00297. doi:10.1177/2325967119S00297
3. Heusdens CHW, Hopper GP, Dossche L, Roelant E, Mackay GM. Anterior cruciate ligament repair with Independent Suture Tape Reinforcement: a case series with 2-year follow-up. Knee Surg Sports Traumatol Arthrosc. 2019;27(1):60-67. doi:10.1007/s00167-018-5239-1

ACL Preservation With the SwiveLock® ACL Repair Kit

Gregory S. DiFelice, MD (New York, NY), demonstrates an anterior cruciate ligament (ACL) primary repair using his pioneering SwiveLock® anchor technique.
The InternalBrace surgical technique is intended only to augment the primary repair/reconstruction by expanding the area of tissue approximation during the healing period and is not intended as a replacement for the native ligament. The InternalBrace technique is for use during soft tissue-to-bone fixation procedures and is not cleared for bone-to-bone fixation.

ACL Primary Repair Using the InternalBrace™ Technique

SwiveLock® ACL Primary Repair Implant System Surgical Technique ACL Primary Repair Described by Gregory S. DiFelice, MD Over the past decade, there has been a renewed interest in primary repair as a potential treatment for certain patterns of ACL rupture. Primary ACL repair, performed through an arthrotomy, was largely abandoned by the mid-1990s due to unpredictable and inconsistent clinical outcomes. However, careful analysis of the older data reveals that certain subgroups, especially patients with proximal tears and good to excellent tissue quality, had better clinical outcomes than the group as a whole.1 In addition, studies reporting outcomes of remnant-preserving ACL surgeries have shown encouraging results with a higher potential for early healing and better functional outcomes as compared to remnant-resecting surgery. Preservation of the native ACL using the described arthroscopic primary repair technique can achieve short-term clinical success in a carefully selected subset of patients with proximal avulsion-type tears and good to excellent tissue quality. Primary repair, as described, has resulted in good to excellent clinical outcomes at average 3-year follow-up.2 Smaller cohorts of patients have also shown durability of results past an average of 60 months, while early comparative cohorts between repair and reconstruction have not revealed significant differences in outcomes.3 Arthroscopic primary repair is a conservative approach to ACL surgery in that no grafts need to be harvested, no tunnels need to be drilled, and revision surgery, if necessary, is more analogous to a primary reconstruction.4 The goal of the procedure is to preserve the remnant native ligament when conditions allow, which will not be for all patients. By doing this, the native nerve endings and blood supply are preserved. In light of the significant reduction in morbidity to the patient, in combination with preservation of native anatomy, meaningful recovery time is greatly reduced.5 In a retrospective study, patients were contacted to complete the forgotten joint score questionnaire between 2 and 5 years following surgery. Based on the data in this study, patients undergoing arthroscopic primary ACL repair can expect to have significantly less daily awareness of their operated knee at short- to midterm follow-up as compared with patients undergoing ACL reconstruction.6 Patient Selection When selecting a patient who may benefit from primary ACL repair, it is critical to appropriately evaluate two variables: the acuteness of the injury and the tear pattern. A higher percentage of successful outcomes with primary ACL repair has historically been seen in patients with acute injuries that were addressed within the first 4 weeks post injury and in those with proximal tear patterns (Figures 1 and 2).7,8 Other variables, such as age, activity level, tissue quality, and injury mechanism, also need to be considered in the surgical decisionmaking process when choosing between primary ACL repair and the more conventional ACL reconstruction. Based on several early outcome studies in younger patients, it appears that ACL repair should be used cautiously in this cohort. 02 I SwiveLock® ACL Primary Repair Implant System Figure 1: Sagittal T1 MRI Figure 2: Coronal PD MRI showing proximal ACL tear showing proximal ACL tear. Note that fibers do not contact the femoral wall Technique Evaluation With the implementation of modern-day technology, such as magnetic resonance imaging for patient selection, arthroscopy for minimally invasive surgery, advanced rehabilitation programs for stiffness prevention, and suture anchors for direct tensioning, it has been shown that outcomes of arthroscopic primary repair in patients with proximal tears are significantly better than the historic experience.9 This arthroscopic ACL repair procedure should be performed only on modified Sherman Type I or Type II tears. Modified Sherman Type I ACL tears are true soft-tissue avulsions with up to 10% of the length of the ligament tissue left attached to the femur, whereas modified Sherman Type II ACL tears have up to 25% of the tissue left attached to the femur.10 Type I tear Type II tear SwiveLock® ACL Primary Repair Implant System I 03 Surgical Technique 1 Use standard arthroscopic portals including anterolateral viewing portal and anteromedial (AM) working portal. The PassPort Button™ cannula is used for suture management in the working portal to optimize visibility and maneuverability inside and outside the joint while aiding in suture management. The 8 cm × 3 cm version is most frequently used. The ligamentum mucosum, if intact, is usually resected, and a portion of the fat pad is resected to optimize visualization. 2 Suture passage through the ACL tissue begins at the intact base of the ligament distally and progresses toward the proximal end. Pass a #2 FiberWire® suture through the AM bundle of the ACL using the FastPass Scorpion™ suture passer (a). After the first pass, alternate passes with opposite ends, creating a Bunnell-type stitch pattern running up the AM bundle. In a normal length ACL, a total of 3 to 5 passes can be performed with each limb of the FiberWire suture. The final bite should exit the avulsed end of the ligament to ensure that the tissue sits flush to the femoral wall after repair. (a) 04 I SwiveLock® ACL Primary Repair Implant System 3 (a) With tension on both FiberWire An inferomedial accessory portal is made. The FiberWire® suture is retrieved and parked outside the accessory incision. The same technique is performed using a #2 TigerWire® suture in the posterolateral (PL) ACL bundle. Similar to the AM bundle, 3 to 5 passes are typical for the PL bundle. As more passes are performed, the risk of transecting already placed sutures increases. It is important to be aware of the tactile feedback provided by the FastPass Scorpion™ suture passer during suture passing. If abnormal resistance is encountered when delivering the Scorpion needle, the pass should be aborted and the FastPass Scorpion suture passer should be redirected and suture passage reattempted. The final bite should exit the avulsed end of the PL bundle toward the wall of the femur to ensure that the tissue sits flush to the femoral wall after repair. At this point, the TigerWire sutures are retrieved via the inferomedial accessory portal, and the FiberWire sutures are retrieved through the PassPort Button™ cannula in preparation for ACL fixation. and TigerWire sutures to retract the ACL, the native ACL bony origin can be roughened with a burr. Once roughened, or in sequence with roughening, a PowerPick™ instrument (a) can be used to fenestrate the ACL footprint to optimize the healing environment. Alternatively, a small opening anterior notchplasty can be performed. (a) SwiveLock® ACL Primary Repair Implant System I 05 4 Placement of the suture anchors directly into the femoral footprint of the ACL will occur through the inferomedial accessory portal. With the knee in 115˚ of flexion, the 2.4 mm in-line drill guide is inserted towards the origin of the posterolateral bundle on the femur. Then the in-line drill is now drilled to the depth of the first laser etch mark or until the proximal laser line meets the drill guide. The drill hole is then tapped with a 4.75 mm SwiveLock® punch tap. Note: Some surgeons prefer to visualize the ACL femoral footprint via the medial portal to optimize visualization and placement of the drill holes and anchors. The TigerWire® sutures are retrieved through the inferomedial accessory portal and loaded into the eyelet of the 4.75 mm BioComposite SwiveLock anchor. With the knee still in 115˚ of flexion, the SwiveLock anchor is inserted into the drill hole in the PL bundle origin and the sutures are tensioned. The eyelet of the anchor is advanced into the bone socket until the anchor body contacts bone. With the sutures tensioned appropriately, advance the screw by holding the thumb pad while the turning the inserter handle clockwise. The anchor is fully deployed when the screw is flush or slightly countersunk into the bone. 5 06 I SwiveLock® ACL Primary Repair Implant System Remove the orange suture cleat tab on the handle of the SwiveLock anchor to release the retention suture and remove the driver. Pulling one limb of the retention suture will allow it to be fully removed from the implant. Alternatively, the retention suture can be retained and used to fortify the ACL fixation per surgeon discretion. Next, cut the free ends of the repair sutures with an open-ended suture cutter so that they are flush with the edge of the bone socket. 6 With the knee at 90˚ of flexion, insert the 2.4 mm in-line drill guide through the inferomedial accessory portal toward the origin of the AM bundle. Then drill the in-line drill to the depth of the first laser etch mark or until the proximal laser line meets the drill guide. 7 Then tap the drill hole with a 4.75 mm SwiveLock punch tap. Retrieve the FiberWire® sutures through the inferomedial accessory portal and load the sutures into the eyelet of the 4.75 mm BioComposite SwiveLock® anchor with the extended length FiberTape® suture loop for the InternalBrace™ technique. With the knee still at 90˚ of flexion, insert the SwiveLock anchor into the drill hole in the AM bundle origin and tension the sutures. Advance the eyelet of the anchor into the bone socket until the anchor body contacts bone. The anchor is fully deployed when the screw is flush or slightly countersunk in the bone. Now remove the orange suture cleat tab on the handle of the SwiveLock anchor to release the retention suture and remove the driver. Pulling one limb of the retention will allow it to be fully removed from the implant. 8 With the FiberWire suture left in place, the free ends of the repair sutures are cut with an open-ended suture cutter so that they are flush with the edge of the bone socket. Then retrieve the FiberTape suture out of the AM portal for later use. The InternalBrace surgical technique is intended only to augment the primary repair/reconstruction by expanding the area of tissue approximation during the healing period and is not intended as a replacement for the native ligament. The InternalBrace technique is for use during soft tissue-tobone fixation procedures and is not cleared for bone-to-bone fixation. SwiveLock® ACL Primary Repair Implant System I 07 9 Use the RetroConstruction™ tibial ACL marking hook and the 2.4 mm drill sleeve to localize centrally into the anterior third of the ACL tibial insertion. Then drill the 2.4 mm cannulated drill into the joint. Once in position, remove the ACL drill guide, leaving the 2.4 mm cannulated drill pin in the proximal tibia. The trocar is removed from the cannulated drill allowing a lasso wire to be delivered through the cannulation of the drill until it is visualized in the joint. (a) Now retrieve the lasso wire through the PassPort Button™ cannula with a KingFisher® grasper. Advance the lasso wire until the opposite end of the wire is no longer visible at the back end of the cannulated drill (a). Chuck the cannulated drill and carefully remove it from the tibia. Pay attention to the lasso wire to ensure it remains visible in the distal aperture of the tibial tunnel. 10 With both the lasso wire and the FiberWire® suture in the PassPort Button cannula, the single strand of the FiberWire suture can be inserted through the wire lasso loop, and then retrieved distally through the ACL insertion and tibial bone tunnel. 08 I SwiveLock® ACL Primary Repair Implant System Final Fixation: Using the drill guide and 2.4 mm cannulated drill, drill a hole 1 cm distal to the tibial bone tunnel to the laser mark at the drill flutes. The 4.75 mm SwiveLock® tap is then used to prepare the hole. Now pass the FiberTape® suture through the eyelet of the 4.75 mm BioComposite SwiveLock anchor. With the knee in full extension and with tension on the FiberTape suture, deploy the 4.75 mm SwiveLock anchor in standard fashion to complete the InternalBrace™ technique. 11 Now remove the orange suture cleat tab on the handle of the SwiveLock anchor to release the retention suture and remove the driver. Pulling one limb of the retention suture will allow it to be fully removed from the implant. The FiberTape suture can be cut flush with the bone. A physical exam of the knee should reveal full range of motion with a negative Lachman exam at this point. Note: Do not apply extra tension to the FiberTape sutures after the SwiveLock anchor is inserted into the tibial socket. Postoperative Care Described by Gregory S. DiFelice, MD Postoperatively, during the first month, the main objectives are controlling swelling and restoring range of motion and quadriceps control: A brace is worn for the first month with weight-bearing as tolerated. The brace is locked in extension until volitional quadriceps control has returned at which point the brace can be unlocked for ambulation. Immediately after surgery, use intermittent cold therapy with compression. Range-of-motion exercises are initiated in the first few days after surgery in a controlled fashion. The morbidity of this procedure is far less than with a standard ACL reconstruction, and therefore, many patients can make significant progress by doing the exercises on their own.5 Hence, formal therapy does not necessarily have to start until after the first month. Decisions in this regard should be made on a caseby-case basis. After one month, patients are quickly weaned off of the brace. At 4 to 6 weeks postoperatively, patients are advanced to gentle strengthening and placed on a standard ACL rehabilitation protocol. SwiveLock® ACL Primary Repair Implant System I 09 Ordering Information Product Description Item Number ACL SwiveLock® Anchor Repair Kit AR-1594 8 mm × 30 mm PassPort Button™ Cannula 2.4 mm Crown-Tip Drill Guide 2.4 mm Cannulated Drill w/ SutureLasso™ Suture Passer SD Loop #2 TigerWire® Suture #2 FiberWire® Suture 4.75 mm SwiveLock Anchor Punch/Tap (2x) BioComposite SwiveLock Anchor 4.75 mm × 19.1 mm SwiveLock Anchor 4.75 mm × 19.1 mm w/ Extended Length FiberTape® Loop Product Description Item Number 2.4 mm Cannulated Drill w/ SutureLasso Suture Passer SD Loop AR-1594D-24 Instruments Product Description Item Number FastPass Scorpion™ Suture Passer AR-13999MF PowerPick™ Instrument AR-8150PX-45 KingFisher® Suture Retriever AR-13970NR Open-Ended Suture Cutter AR-16794L FiberTape Suture Retriever AR-13974NR Tibial ACL Drill Guide AR-1510T RetroConstruction™ Drill Guide Handle, side release AR-1510HR Ratchet Drill Sleeve, 2.4 mm AR-1510FD-24 Spade Tip Drill for 5.5 mm Corkscrew® FT and 4.75 mm and 5.5 mm SwiveLock anchors AR-1927D Cannulated Drill, 4 mm AR-1218-40 Cannulated Drill, 4.5 mm AR-1218-45 5.2 mm tap for 4.75 mm SwiveLock anchor AR-1593-5 Products advertised in this brochure/surgical technique guide may not be available in all countries. For information on availability, please contact Arthrex Customer Service or your local Arthrex representative. 10 I SwiveLock® ACL Primary Repair Implant System References 1. van der List JP, DiFelice GS. Role of tear location on outcomes of open primary repair of the anterior cruciate ligament: a systematic review of historical studies. Knee. 2017;24(5):898-908. doi:10.1016/j.knee.2017.05.009 2. Jonkergouw A, van der List JP, DiFelice GS. Arthroscopic primary repair of proximal anterior cruciate ligament tears: outcomes of the first 56 consecutive patients and the role of additional internal bracing. Knee Surg Sports Traumatol Arthrosc. 2019;27(1):21-28. doi:10.1007/s00167-018-5338-z 3. Kandhari V, Vieira TD, Ouanezar H, et al. Clinical outcomes of arthroscopic primary anterior cruciate ligament repair: a systematic review from the scientific anterior cruciate ligament network international study group. Arthroscopy. 2020;36(2):594-612. doi:10.1016/j.arthro.2019.09.021 4. DiFelice GS, Villegas C, Taylor S. Anterior cruciate ligament preservation: early results of a novel arthroscopic technique for suture anchor primary anterior cruciate ligament repair. Arthroscopy. 2015;31(11):2162-2171. doi:10.1016/j.arthro.2015.08.010 5. Gagliardi AG, Carry PM, Parikh HB, et al. ACL repair with suture ligament augmentation is associated with a high failure rate among adolescent patients. Am J Sports Med. 2019;47(3):560-566. doi:10.1177/0363546518825255 6. Vermeijden HD, van der List JP, O’Brien R, et al. Patients forget about their operated knee more following arthroscopic primary repair of the anterior cruciate ligament than following reconstruction. Arthroscopy. 2020;36(3):797-804. doi:10.1016/j. arthro.2019.09.041 7. van der List JP, DiFelice GS. Preoperative magnetic resonance imaging predicts eligibility for arthroscopic primary anterior cruciate ligament repair. Knee Surg Sports Traumatol Arthrosc. 2018;26(2):660-671. doi:10.1007/s00167-017-4646-z 8. van der List JP, Jonkergouw A, van Noort A, et al. Identifying candidates for arthroscopic primary repair of the anterior cruciate ligament: a case-control study. Knee. 2019;26(3):619-627. doi:10.1016/j.knee.2019.02.004 9. DiFelice GS, van der List JP. Clinical outcomes of arthroscopic primary repair of proximal anterior cruciate ligament tears are maintained at mid-term follow-up. Arthroscopy. 2018;34(4):1085-1093. doi:10.1016/j.arthro.2017.10.028 10. van der List JP, Mintz DN, DiFelice GS. The location of anterior cruciate ligament tears: a prevalence study using magnetic resonance imaging. Orthop J Sports Med. 2017;5(6):2325967117709966. doi:10.1177/2325967117709966 SwiveLock® ACL Primary Repair Implant System I 11 This description of technique is provided as an educational tool and clinical aid to assist properly licensed medical professionals in the usage of specific Arthrex® products. As part of this professional usage, the medical professional must use their professional judgment in making any final determinations in product usage and technique. In doing so, the medical professional should rely on their own training and experience, and should conduct a thorough review of pertinent medical literature and the product’s directions for use. Postoperative management is patient specific and dependent on the treating professional’s assessment. Individual results will vary and not all patients will experience the same postoperative activity level and/or outcomes. View U.S. patent information at www.arthrex.com/corporate/virtual-patent-marking © 2021 Arthrex, Inc. All rights reserved. | www.arthrex.com | LT1-000174-en-US_D

SwiveLock® ACL Primary Repair Implant System

ACL Primary Repair Scientific Update: A Review of Modern Techniques

InternalBrace™ Technique: Knee Applications

Kreuzbandnaht

Child (D)

Das ACL Repair-TightRope-Implantat ist ein innovativer Ansatz für den Erhalt des vorderen Kreuzbandes und ermöglicht ein präzises, schrittweises Spannen und Nachspannen der Naht. Darüber hinaus ermöglicht der neue FiberRing-Faden einen vereinfachten und reproduzierbaren Fadendurchzug und eine bessere Implantatbelastung. Eine sorgfältige Analyse früherer Daten hat ergeben, dass bestimmte Untergruppen von Rissen des vorderen Kreuzbandes, insbesondere proximale Risse mit guter Gewebequalität, bei der ACL-Primärrekonstruktion positive klinische Ergebnisse aufweisen.1
Referenz
1. Arthrex, Inc. DOC1-000178-en-US_B. Naples, FL; 2020.

Rachel M. Frank, MD (Denver, CO), demonstrates the reduction of a tibial spine avulsion fracture (ACL tear equivalent) using the ACL Repair TightRope® implant and FiberRing™ suture.

Tibial Spine Avulsion Fracture Reduction Using ACL Repair TightRope® Implant and FiberRing™ Suture

Patrick A. Smith, MD (Columbia, MO), reviews current literature evaluating the biomechanics for primary ACL repair using the InternalBrace™ ligament augmentation procedure and discusses subsequent clinical outcomes.
The InternalBrace surgical technique is intended only to augment the primary repair/reconstruction by expanding the area of tissue approximation during the healing period and is not intended as a replacement for the native ligament. The InternalBrace technique is for use during soft tissue-to-bone fixation procedures and is not cleared for bone-to-bone fixation.

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ACL Tears: Literature Review on Primary ACL Repair

Gregory S. DiFelice, MD (New York, NY), demonstrates a primary PCL repair using the PCL Repair TightRope® implant and FiberRing™ sutures.&nbsp;

#2 FiberRing , blauer Faden mit Durchzugsschlaufe, 35mm

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ACL Repair TightRope®-Implantat mit FiberRing™-Fäden