Name: Advancements in All-Inside ACL/PCL Reconstruction
Uploaded: 2020-01-15T00:00:00Z
Channel: Arthrex
Description: Elizabeth G. Matzkin, MD (Boston, MA), presents on advancements in all-inside ACL/PCL reconstruction.

<p>Elizabeth G. Matzkin, MD (Boston, MA), presents on advancements in all-inside ACL/PCL reconstruction.</p>

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VID1-000739-en-US | A | Advancements in All-Inside ACL/PCL Reconstruction

Elizabeth G. Matzkin

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Advancements in All-Inside ACL/PCL Reconstruction

All right. So we're going to start off the morning talking about all inside ACL PCL reconstruction. So ACL reconstruction what has changed. Tons. So over the last ten years techniques have changed. We've gone from two incision ACL reconstruction to Transtibial to Anteromedial portal to you know, all inside guides have changed. Tunnel position has changed. We're really looking for those anatomic tunnels now. Fixation has changed tremendously. Graph choices have changed. And we're going to talk a little bit about the new surprise that you guys are going to get to play with in the lab a little bit later. So you can see in these pictures we've gone from metal interference screws to biocomposite. And now to more suspensory fixation with tight ropes. We can use buttons. So our options have improved dramatically. And as our options and our technology has improved, so is our Techniques. So BTB graphs, these have kind of been the traditional graph that we've talked about. Still kind of touted for our contact athletes. But I think that spectrum and that needle is going to continue to change. Btb graphs, they have a history of leaving some anterior knee pain, probably some fracture risk. Fixation was traditionally with interference screws. We now have a way that we can use our suspensory fixation and still do all-inside with a BTB graft. You do have to worry a little bit about graft size mismatch with tb's. And when we take a BTB graft and we take a 9 to 10 millimeter wide graft, it is wide. It's not diameter. So I think think about that as we talk about the rest of these graft types. So graft preparation for a BTB. If you're going to do an all inside technique, we'll usually flip one side of the bone graft or one side of the bone down. We can suture in our TightRope makes a nice graft. Appropriate length for an All-inside makes it just a little bit shorter, so you don't have to have those full length tunnels. Arthrex has a really great video on how to do to do this. Hamstring grafts. Traditionally we took our semi, our gracilis, we doubled them over and unfortunately every now and then you'd end up with a 7 or 8 millimeter graft. That's not acceptable. The mantra in my Or is I never put anything less than nine millimeters in anybody. We know from the literature that eight millimeters or less has a much higher retail rate failure rate. So don't put small grafts in anybody. Nowadays we can quadruple our semitendinosus tendon. This has really changed my practice. I can spare the gracilis, but what I do is I never get less than a nine millimeter graft, even in my small female athletes. Fixation can use interference screws can use suspensory fixation. Quadrupled summit. You know, we published a paper on how you can even kind of pre measure the length of your tendon to and measure the width and the length to predict what your final length and diameter will be when you quadruple it. So it makes it really easy when you're doing your tunnels and whatnot With this technique, quad tendon, I think this is going to be the up and coming graft for sure. There is less complication risk than BTB. It is more robust than a BTB graft. So when you take a quad tendon graft and you measure 9 or 10mm wide, you're getting a 9 or 10 millimeter diameter. It's very different than when you take a patellar tendon graft. This is a much more robust graft. I think patients are going to have much less anterior knee pain. The fracture risk is not there. We have some new ways that we can do all-inside with quad tendon now. So I think this is really going to become a more and more popular graft over the next couple of years. Allograft certainly avoid this in our younger patients. Pretty good for our older weekend warriors. Very good for revisions. This does come pre-made. Arthrex has made these graphs for us and packaged them up. You can get a tibialis, a peroneus or a semi T, so, you know, for cases where you don't have an assistant and you want to use an allograft, you can get a pre-made graft, you can pick your diameter and pick your length so it can save some time. This is a quick video. Oh hold on. That was a quick video. This is a that I'm going to just roll through really quick on how we prepare our quadrupled semi tendinosis tendon because the technique itself is not that hard, but you have to have a pretty good Graf prep. So we take our semitendinosus, we quadruple it over, we have TightRope on both sides. We suture these two ends of the tendon together. I'm going to fast forward. We once we are sutured, we send our needle through the end of the tendon. Here. You just need to make sure you don't pierce that white suture. Or it will change your fixation. We'll send a couple stitches circumferentially around, and what you end up with is this really nice, robust semitendinosus graft. And so you can see there, It's really worked well for most of my patients. Internalbrace is becoming popular. So to brace or not to brace? How many in this room are doing internal braces with their ACLs? So very few. We'll see where this goes. I think there's going to be a lot more data coming out on this. This is basically sending a FiberTape suture alongside your ACL graft. That suture can be put into your TightRope on the femoral side and usually fixed distally with a SwiveLock. There was a recent article out just in June this summer that looked at this, and it showed that suture augmentation with hamstring ACLs demonstrated improved patient reported outcome measures, less pain in a higher percentage of an earlier return to pre injury activity level when compared to a standard hamstring ACL reconstruction. And there was no evidence of over constraint. So you know maybe a good way to help give our grafts some support is their healing. And as patients start to get to get active. So the FlipCutter is what really allows us to do these all inside techniques. So the FlipCutter is allows us with the guide to put our femoral tunnel anywhere we want. And the nice thing about this versus using an anteromedial portal is that one, you can avoid your posterior wall blowout, but two, you can predetermine the length of your femoral tunnel so you don't have to worry about getting too short a tunnel because you can move your guide along that lateral femur just enough to make your tunnel as long as you need. Which saves a lot of the concerns with using Anteromedial portal. The nice thing about this is this is one FlipCutter, and you can dial in your size so you can even adjust your tunnel diameter from femur to tibia and not have to open a second FlipCutter. So we're going to get to try these in the lab. I'm really looking forward to using it. I haven't used it in practice yet, but I think it's going to be awesome. This is a quick video that shows how this is done. This is actually a PCL. They're sending the FlipCutter through the femoral side here. You can see it come through. They're dialing in their tunnel diameter. Looks like a 9 or 10mm. And then once they dial it in, they can ream their tunnel. And then once they're done, they just dial it back down and they can pull it out. So this will be fun to play with. You can see they can look at their tunnel length on this knee here. Dialing it back down so that the blade comes back in and they can pull that out. And they should have a nice ten millimeter tunnel to work with. So certainly this is less invasive. You can do these ACL reconstructions through pretty small incisions. Graph passage is pretty easy. Reasons I really, really like this technique in my hands is because once I put my graft in, I have the ability to tension my graft graph on both the femoral and tibial sides till it gets to a tension I like, which is a little bit different than when you use interference screws. Once your screw goes in, you kind of bought what you bought. But once I tighten my graph, I can feel it. I can cycle my knee and I want a little bit more. I can, you know, tighten it up again. So in my hands that has really changed. My practice with regards to doing All-inside ACL reconstruction. It also, I think we have a lot of data. We'll come out with publishing some of this, but I think my post op clinical exam is much better because I'm able to get these graphs pretty tight and taut in there when I put them in. So there's been plenty of studies testing this technique. Biomechanically in the lab, they've looked at cyclic displacement and ultimate load compared to interference screws. This technique has certainly come out both in the lab and plenty of clinical studies demonstrating similar outcomes, because I think anytime you anytime you change technique there's a little bit of apprehension. But all those studies have been done very similarly. We can use the same technique for PCL reconstruction. The Arthrex PCL guide. I don't know how many of you have used it. It's awesome. It really hugs the back of the tibia. It locks itself on there. Once I have my tibial guide on, I send my FlipCutter through my FlipCutter will just butt up against my my guide. My guide comes out, I can tap my FlipCutter in, I flip it, and then when I make my tunnel, I'm pulling towards me. So you don't have to worry about sending a reamer up through the tibia and anything that's behind that posterior capsule. I don't need to have a CRM. I don't need to see where I am when I'm doing my tibial tunnel anymore, and I don't have to worry about injuring anything. I can even let the residents make my tibial tunnel now and not have to worry about them plunging into the back of the knee. So for Pcls, using the FlipCutter has been really nice. And the same thing with, you know, pulling these graphs in and being able to really tighten down that graft from both sides after I put it in has changed everything. So a few pictures here on the top left, you can see that's looking in the back of the knee through a posterior portal. That's the tunnel made with the FlipCutter. You can see the femoral guide on the top right. Pcl is now coming in again, looking through the posterior of the knee. You can see it coming up the tibial tunnel. And then the final picture, once it's getting pulled up into the femoral tunnel. So it makes it pretty easy to do these pcls. So again, why do I like these all-inside GraftLink techniques? Well, one, I can get very anatomic with my guides. I don't need any accessory portals. I don't have to worry about hyper flexing my knee for ACL reconstruction. I don't have to worry about back wall blowout or short sockets when I do an anteromedial technique. I can do a single tendon harvest now. I can quadruple my semi without too much worry about the size and diameter of that graft. My favorite part about this is that is that adjustable cortical fixation, I can dial in that tension. I can keep going back until I'm really happy with what I've got. In graph size. Again, don't put anything less than nine millimeters in your patients. Some SOS data that I have here. So this one is looking at ACL repair with internal brace versus just an ACL without an internal brace. And really the take home from this is the numbers are very similar when we look at the Womac function. This is BTB Autograft versus a GraftLink autograft. And again very similar outcomes with regards to the cues and the activity scores. This is looking at just the Vas scores for an all-inside ACL. Same scores PCL. They kind of mimic each other, but they look quite good. So thank you. I hope everyone will try some of these techniques in the lab today. And I look forward to the rest of the talks. And a really good day.

Advancements in All-Inside ACL/PCL Reconstruction

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