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DVD-1104 | A | ACL Reconstruction using RetroButton®

Randy Schwartzberg

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.

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

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ACL Reconstruction using RetroButton®

I'm doctor Randy Schwartzberg from Orlando, Florida. I'm going to demonstrate ACL reconstruction with RetroButton fixation on the femur and RetroScrew fixation on the tibia. The advantages to RetroButton fixation on the femur are that it's quick, easy, reproducible, and provides very strong and stiff fixation. This is our tibialis anterior tendon allograft. I've drawn out two numbers for you. The 45 millimeter length that you see right here goes from the looped part of the graph to the start of the suturing. The reason for that is that there will be 20mm of graft inside the femoral socket, and another 25 in the joint. The reason that the 50mm of suturing has been done is because that is going to be the anticipated length of our tibial tunnel. This is an eight millimeter sizer and this looks perfect for our femoral socket. Nine millimeters is going to be perfect for our tibial tunnel today. For a single bundle ACL reconstruction, my preference is to split the difference and go right in the middle of the ACL footprint. So we're really going to reproduce part of the posterolateral and part of the anteromedial bundles. And we're going to do the same thing on the femur. I've chosen one of our over the top guides. And next to it you can see the RetroButton pin. The RetroButton pin is calibrated. It has a it has a spade tip. And the purpose of the calibrations is going to be to allow us to measure the distance from the most inner aspect of our femoral socket on the femoral socket and the femoral cortex. At this point, what we're going to do is we're going to assemble the RetroButton pin into the over the top guide. In a retrograde fashion to allow the easy one sequence, one step femoral tunnel preparation. Okay, we've got our over the top guide with our RetroButton pin inside of it. And for the for this technique, I like to ream the femoral tunnel from the anteromedial portal. It allows us to get lower on the wall down to that 2:00 position. And in order to do this, we're going to hyper flex the knee. And at this point, what we're going to do is we're going to hook up our drill to our RetroButton pin. Once our pin is in place, we can take the over the top guide back just a little bit. And the reason for that is we want to see the the calibrations on the pin. And what we want to do is we want to know when that pin encounters and goes through the femoral Vortex. 30. 35. That's the 40 mark. Looks like it's going to go through it around 45. There is a second way to measure that. If you're not confident that you went through right at 45. We can use a second measuring device which is an outside in measuring device. And before we do that, what we have to do is advance the pin to the thick black line. That thick black line where the 20 millimeter mark is, has to be right at the femoral orifice where the femoral socket will be. This is the RetroButton measuring device. And what we'll do is we'll actually put that over the RetroButton pin and run that down to the bone all the way down till we encounter the cortex. And it's important to make sure that our RetroButton pin inside the joint has not moved, and that we're still on the thick black line, which we are. So it looks like our inside measurement was accurate. Since this comes out at 45, I've placed the eight millimeter reamer through a shoehorn cannula, and the purpose of that is to be able to protect the PCL while we're reaming our femoral socket. We're going to ream our tunnel to a depth of 30mm, because that's going to allow us to have 20mm of graft in the tunnel. And there's there's our 30 millimeter mark. This is how we determine the actual length of our RetroButton loop. There's two measurements that have to be considered. The first measurement is the intraosseous length, which is the measure from the orifice of the femoral socket in the joint to the femoral cortex. And that was measured already, as you saw with our guide and freehand, to be 45mm in length. The length of our femoral socket was 30mm in length. We determined that. So a very simple calculation is the intraosseous length minus the femoral socket. Length 45 -30 is 15. We simply add ten and 25mm is the length of our RetroButton loop. So now what I want to do is I'm going to park a suture loop up in the tunnel. To facilitate later graft passing. And I like to leave it up near the tunnel. This is our nine millimeter RetroCutter. I like to use the RetroCutter to make our tibial tunnels, because it's going to create a nice, concise cylindrical tunnel, and it's going to be cleaner and it's going to allow for better interference fit. And in addition, we're going to be able to place it exactly where we want. We don't have to worry about any guide pins and where they may come out. Okay. And there it is. Right through. Now we'll disassemble it. Here's our graft that's already been prepared with the RetroButton. Here is our RetroButton loop that's 25mm in length. And then we've made a measurement on the graft itself at 20mm from the apex. And the reason for that is that when we go to flip the RetroButton, we're going to want to know that we're right at the femoral cortex at that point. You'll see how that works when we're inside the joint. The last step in graft preparation is suturing together the loop limb right here. And the reason for that is that when we go to tension each graft limb individually, when we fix the graft on the tibia, we do not want the graph to piston and shift around through the RetroButton loop. I like to use a number two FiberWire suture for this, and I like to bury the suture. So we're going to take the lead sutures from the RetroButton, which are number five, caliber FiberWire. We're going to show you still as it comes up into the tibia. And now we're going to go into the joint. The other thing that I like to do here is take the slack out of the button there. Once you get it all the way through the slack out of the sutures. Okay. Now we're going to pass it. We're going to bring it up into the joint so you can see it in the joint before it goes through. An important point is to have the what we'll call the low side of the button facing lateral, which is the part where the RetroButton loop is not going through. So it's the top side, and that's going to facilitate flipping of the button. And this RetroButton is going to flip on its own right when it gets through. There we go. And you can it's a little pop that you feel and it goes right through. And the way to check it is to pull down below good and firm on both strands to know that it's fixed, solid in there. The graft is seated nicely on the femur and now it's time to fix it on the tibial side. You can see just a little bit of suture at the joint, which is exactly what we want. We want our screw to be able to run on that suture. Next up is to pass our guidewire introducer up. And then I'm going to pass our guidewire through it. This is our regular nitinol guidewire used for interference screws. We'll pass our RetroScrew screwdriver over that. Okay. And then we'll pull our guide wire out. Now we're going to place the number two FiberStick through the screwdriver and bring it out the anteromedial portal. You can see the FiberStick coming up into the joint. Now, I like to place a shoehorn cannula through the Anteromedial portal at this point for a couple of reasons. One is to facilitate screw insertion. And when we're doing the all-inside technique, it helps minimize a SutureBridge. That won't be an issue today. We're going to place our grasper through. Grab our FiberStick. And Now. Now it's time to select a RetroScrew. I like to choose a RetroScrew that is either the same diameter as the graft and tunnel, or one size smaller. Here's what it looks like as we pass our FiberStick through the screw. And then what we need to do is tie a mulberry knot on the end of the screw, which is very simple. We can seat the screw in the shoehorn cannula while we do that. I do six twirls. Pull the little suture right through the loop. And create a little mulberry knot. And you really should check that by pulling on the suture. And make sure it doesn't come through the screw. And we just pop it right on in. Then we'll gently remove our shoehorn cannula, and it's time to seat the screw onto the RetroScrew screwdriver. The way I like to do that is I like to use a hemostat. We pull a little gentle tension down on the suture. Our retro screwdriver is now seated into the screw. And what we need to do is tighten our tighten our FiberStick suture down and wrap it around the cleat on the RetroScrew screwdriver. I also like to. Use this specially designed device to help get the screw started, and hold it down in particularly hard bone. This is called the RetroScrew tamp and I like to call it the closure. Now we'll start out with the knee slightly flexed and we will extend the knee once it becomes engaged. I'm using a reverse threaded technique. Getting excellent purchase against the anterior portion of our graft. Excellent tension. We'll remove our screwdriver. Simply by wiggling it out. And then we'll remove our FiberStick through the anteromedial portal. And you can see our RetroScrew giving us excellent aperture fixation. The last step will be to extend the knee to make sure that we don't have any graft impingement. And you can see with the graft placed in an anatomic position, full extension is easy with no graft impingement.