Name: Double Bundle ACL Reconstruction with Bioabsorbable RetroScrew® Fixation
Uploaded: 2012-05-18T00:00:00Z
Channel: Arthrex

Knee

Not Hidden

English  - en

video

DVD-1072 | A | Double Bundle ACL Reconstruction with Bioabsorbable RetroScrew® Fixation

Craig Morgan

Human

A video recording of a surgical technique on a live patient in an operating room setting or a cadaveric demonstration.

Eine Videoaufnahme einer Operationsanleitung an einem lebenden Patienten oder Patientin in einem Operationssaal oder eine Demonstration an einem Humanpräparat.

Operationstechnikvideos

Surgical Technique Videos

Gravação em vídeo de uma técnica cirúrgica em um paciente em uma sala de cirurgia ou uma demonstração cadavérica.

Vídeos de técnicas cirúrgicas

Grabación en vídeo de una técnica quirúrgica de un paciente en un quirófano o una demostración cadavérica.

Videos de técnicas quirúrgicas

Double Bundle ACL Reconstruction with Bioabsorbable RetroScrew® Fixation

Within the last several years, and most recently, there's been a progressive, growing interest in the concept of a double bundle ACL reconstruction. And I think part of this may be an outgrowth of what we've been learning in the last 5 or 6 years with the double bundle PCL. The double bundle technique, as you will see today, was developed over the last 3 or 4 years in an attempt to make a simple procedure that can technically be achieved, rather than have it be a complicated technical feat. I like to start preparing the graph before the patient's asleep. This is a tibialis tendon allograft. This particular one measures 25cm in length and at its thickest part here is about a centimeter in width. So what we like to do is we want to divide it in its mid portion. Now, David Caban has done extensive studies on pull out the failure of multiple graphs and has shown that if you do a baseball stitch of either FiberWire or Arthroman and FiberWire is better because of its increased strength for the length of where your interference screw is going to be, that you will increase your pull out to failure by somewhere between 20 and 30%, so that the apex of this will end up in the femoral socket. And I know my screws 20mm. So I'm going to run a baseball stitch 20mm down here, 20mm down here. I'm not going to sew them together as one bundle because we're going to be one of these is going to be the postero lateral ACL bundle. And the other is going to be the Anteromedial. That part will be in the femoral socket. The interference screw is going to go between them to separate them so that we create the bundled effect. Then I'm just going to tie this off. And you want to have at the apex of this or what engineers call the bite end, you want to have suture free so you don't have know, some big glob of suture that will block this from going into the getting started in the socket. So now we know that the native ACL averages 28mm in length. So that blue line is going to be at the femoral intra-articular orifice. So what's going to be in the knee and become the ACL is that three centimeter distance. So we've got the femoral side. Now we've got to deal with the tibial side. Then when we're all done we need to size the diameter of this construct once it's put together. Because that's going to determine the diameter of the tunnels we drill. And usually one of these is slightly larger in diameter than the other. I want the larger of the two to be the posterolateral bundle. Prior literature has shown us that the lockman in the pivot shaft largely resides in the posterolateral bundle. I got 20mm of summarization on each limb that's going to go in the femoral socket. I have a three centimeter separation of soft tissue that's going to become my intra-articular ACL double bundle. Then I've got another two centimeters that's going to reside in the upper aspect of the tibial tunnel, and our RetroScrew is going to go backwards against that. The last thing we need to do is get FiberWire purchase on the end of this, so we can tension the graft. So now we want to size our diameter so that we can know what size tunnels to make, because we want this as tight as possible be able to get the graft in. So here's a ten. So ten is tight. That's what we're going to go with. We want to pre-tension our graft because we can get about two millimeters of creep out of that graft. And I want that to happen before I put it into the knee. So I want to stretch this at 15 pounds for a half an hour. This is spring loaded and it's at 15 pounds axial pressure. And you'll notice when we come back a half an hour later, it will be down to like 10 pounds because it's stretched two millimeters. I want that to happen before I put the graft in. So let's look over here. His ligament and mucosa have been all stretched out, and there's his ACL injury. So let's get rid of all of that. We want to assess what this guy's native notch width is. If it's 15mm or so then you don't really need to do a notch. Plasty. Now I want to look right down on the inner corner floor, because I really want to see the true insertion. This is where we're going to be putting the RetroScrew in. And I need to know there's the lateral meniscus the anterior edge. I don't want to take that off. I want to stay medial here. And that pit between I want to be in this pit between the spines. When I come in and I want to see it, and then I want to reference the anterior aspect of the PCL to know where the true my pin's going to come out about right there. So now it's time to make the tibial tunnel. So the sartorius is coming just like that. I want to make a small incision just on the superior surface of the past. Right there. The MCL is right here. There's the sartorius. So I want my tunnel to be right there. Remember, I want a ten millimeter tunnel. So I'm going to expose sub CrossLink. And I'm just going to make a little nick in the cortex so that my pin when I start it doesn't wander. This is our tibial placement guide that references off the PCL. Pretend my fingers. The PCL comes in from the medial portal references off and it places a pin in the cross hairs here 7 to 8mm anterior to the PCL. So now this needs to go in the medial portal. And then I want my pin to come out equidistant between the apex of the medial intercondylar tibial spine and the lateral one. I want to be dead in the middle and I want to be I want to reference off the PCL. So I want to be kind of like that because the portal is above the level of the joint line. Outside on this, it'll usually read about 70 degrees. Perfect. So we're right kind of where we want to be here. So that's pretty darn close. It may be a half a millimeter more medial than lateral, but I can correct that as I go. The distance between here and the front of the PCL is about 7 or 8mm. So if I bring this up an extension right now. And the things that'll that's not going to roof impinge. And you want to use a straight drill bit not an acorn drill. Bit. Post here. There you go. You can see I'm dead center between the spines. Okay. Now outside here, the periosteum on the outside of this tibial tunnel is going to want to go inside the tunnel. And it's going to block getting your graft up there. When I go to push my graft up in there now it can freely go in here. So there's my tibial tunnel and I want to go make my femoral tunnel now. So let's have the offset guide. Now if we look at this 12:00 there, 9:00 there. And I would say maybe 3 or 4 years ago, people were making their grass more vertical. Okay. That gives you pretty, that gives you really, really good. As you get more vertical, you get good AP stability from your single bundle reconstruction, but you do it at the expense of rotational control. But if you come all the way down here, like at 9:00, you'll have great rotational control, but you'll lose anterior posterior control. The whole concept of the double bundle reconstruction is to get both. So I want to come kind of halfway between 9 and 12. And you'll understand I haven't done a notch. Plasty. So true. 9:00 is there. And 212 true. 12:00 is there. If I took this notch back five millimeters over here, then what you thought was 10:00 really becomes 11:00 in your mind and you can get confused. That's why I don't like to do notch places unless I have to. So I want to go over the top there and I if any, I want to cheat a little about right there. Now I'm going to make a femoral socket. So now what I want to do is just make a little footprint. See. And I can see I got back wall and I'm going to be fine. Okay. So now I'm going to go in three centimeters which is going to be about right there. Here's our joint line. 12:00 right there. 11:00 there. 1030 is here. My aunt I want to now notch this so that I got an anteromedial bundle here. And then my posterior lateral bundle will be way down there. It's 7:00 and 1:00 within your tunnel for the two bundles. This tool allows you by advancing it forward. That's a five millimeter notch that it will create. Now you can really see the geometry of this. I just want to round this off a little bit. So because this guy has such hard bone I don't really want an abrasive surface here. I'm going to look at this socket from the medial portal. The distance between there and there is 21mm and the socket is in the center. So we want to go up here past the central tibial tunnel, past the PCL in the center of the femoral socket and out the distal lateral thigh. When I this thing's been for 35 minutes. It's been stretched at or 15. We started out at 15 pounds. Longitudinal destructive force. Now this thing reads 12 pounds. And what's really happened is this is lengthened by three millimeters. So what I'm going to do is I'm just going to put a line on that one. So I want that to be past the posterior lateral bundle. So we want to go up past the PCL. Okay. Now the way this is going up, the one I wanted to be posterolateral is oriented like Anteromedial. So I want to turn this like that. Pull! Pull, pull! Good. There you go. Stop! So now they're oriented. So now we want to put our femoral sided screw in first. Our screw is actually going to come into the joint from this medial portal. And this prevents screw hang up through the fat pad which is over there. This is a retro screwdriver. It's got a hex sort of orientation here. It's fully cannulated. And it has a number two FiberWire threaded from the back end up through its full cannulation past the tip. And I like to have about six inches of suture sticking out the working end of it. Now what I will do is, is I want to bring this screwdriver up through the tunnel anterior to the graft to about here. And then if I withdraw it, it leaves a loop of suture. I want to come in through my slotted cannula and pick that suture up. So now all I'm going to do is tie an interference knot so that. Now if I If I pull on this, that knot will abut the tip of the screw, and it's got nowhere else to go but go into the joint backwards. Now I'm just going to pull on the suture on the back of this, and it'll pull the screw onto the screw driver. How hard was that? Now, if I screw the screw in right now, then the suture will be trapped in there. So what I'm going to do is take the suture out now by pulling out here. And so what I want to do is bring this anteromedial bundle. Up a little bit. Like that. So that I can get the screw driver between the bundles. So now I'm going to advance the screw up. Until the screw head is buried inside the orifice by about one millimeter, and you can hear the noise it makes. And that's that noise you want to hear. Now I'm going to pull the screw driver out. When I put this RetroScrew in, I want this posterior bundle to be more like over there. That's more anatomic. I want to put my screw lateral and anteriorly. Okay. Now I'm going to take the screw driver and I want to come up anterolateral to all this stuff right there. This time I'm using this little nitinol wire because I've already got my RetroScrew for the tibia preloaded in my cannula. So now what I need to do is pull this wire. Then I'm going to take this obturator behind the screw and just push it in. Now it's in the joint. Then I'm going to pull that like that. Now I'm going to just turn the screw driver down just a little bit. And then there we are. Now to maintain the screw on this so that I can screw backwards. There are these two little posts. And I'm going to do a figure of eight around them. And then I need to make sure that my posterior bundle is going behind there. Now you're pulling on both bundles hard. I want you to range the knee flex. Good. Extend. Good. Okay. Come right about there. Midrange right there. I'm screwing backwards which is counterclockwise. And so we're going to screw it in until the screw head is flush with the floor. And look where the posterior bundle is. It's directly posterior where you want and you want. Then the other bundles anteromedially. Now each one of those bundles is eight millimeters in diameter okay. So that's about exactly what we want right there okay. Now we're going to release the suture out here. And I'll pull that out. And there's our completed reconstruction. Now you'll notice we don't have impingement on the lateral wall like you're used to with a posterior bundle. See the anterior bundle. Relax and extension. There's no roof impingement. And then as I come in flexion right there they're equally tensioned which is mid-range flexion. And now as I come in full flexion here the posterior bundles relax somewhat. But you'll notice I have rotational control here. Inflection. The anterior band is tensioned well there now. And the posterior bundle is also it's not it's it's slightly loose. Now extend. Stop there. We're in about 65 flexion. These are both tension. Well they're come in extension a little bit more. They're both well tensioned. Now as we come we're only in 20 degrees of flexion. Now the anterior band is relaxed just like just like a normal ACL. There's about a millimeter of play. But look at this one. The posterior bundles tension. Well, they're now coming into full extension. Full extension. Good. Right there and then our posterior bundle. It's a tension. Well there we've done with our preliminary studies going on now where we do in cadaveric reconstructions we're putting mini hall effect strain gauges on the on the native ACL posterior bundle. As well as these double bundle reconstructions, we're getting the same sort of reciprocal tension handoff and flexion extension with these reconstructions. But you see, we've got what Savio Wu is talking about about rotational control here at 9:00. And you see we've got collagen from 10:00 to 12:00. So we've accomplished both goals. He has absolutely no lock when 20. He's rock hard stable 60. He's rock hard stable. And the beauty of this case is at 90 he's got no draw. You'll never get that with a single bundle. Reconstruction. For information on the Arthrex Surgical Skills Training program, contact Arthrex or visit the Arthrex website at arthrex.com.