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VID1-001542-en-US | B | MCL and POL Reconstruction: FiberTag® TightRope® Fixation Using the InternalBrace™ Technique

Scott T. Watson

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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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MCL and POL Reconstruction: FiberTag® TightRope® Fixation Using the InternalBrace™ Technique

We're going to demonstrate an all TightRope reconstruction of MCL and posterior medial corner using internal brace augmentation. Here we've got an Achilles allograft prepared here with a FiberTag TightRope assembled on the femoral side. We've added our internal brace, which will be passed with the superficial MCL, as well as a trailing stitch into the back end of the TightRope to aid in flipping of the button on the far cortex. So you see here we've got the Achilles allograft sized to a nine millimeter graft on the femoral side, which is then split into the superficial MCL limb of at least 150mm in length, with an additional FiberTag TightRope trailing stitch. This limb of approximately 120mm will be our posterior oblique ligament, and also has a FiberTag TightRope that has been lengthened and will serve as the fixation on the tibial side. So for this example, we've made an extensile medial approach for this combined MCL posterior medial reconstruction, which we would consider for a more severe medial injury and anteromedial rotatory rotary instability combined with an MCL tear. To orient you, you have the tendons isolated here which have been dissected out, which we'll pass our MCL graft under. So we have our native MCL here that continues distally underneath the tendons for the tibial insertion with the posterior oblique ligament proximally, saphenous nerve can be visualized here right in the field. And then for the posterior oblique ligament posterior medial corner reconstruction we identify our semimembranosus tendon which my clamp is underneath back here which will pass our pol graft around. So we've retracted our saphenous nerve posteriorly and identified the semimembranosus insertion posterior immediately as our landmark. For the posterior medial corner. We'll place a passing suture around this tendon for later passage of our posterior ligament graft. The isometric point of the MCL origin is identified with the use of fluoroscopy with a spade tip pin. We'll begin our reconstruction on the femoral side with identification of the Of the isometric point at the intersection of the posterior femoral cortex and blumenstrasse. Line is identified by the pin on the fluoroscopy image. The native MCL has been tagged for this demonstration with a suture which is at the origin of the MCL of the femur. Our spade tip guide pin is in advanced, slightly anterior and proximal as we go laterally. Once the spade tip is advanced out the lateral cortex, we can pull back and reference our length on these calibrations for our intraosseous tunnel length. Spade tip pin is advanced out the lateral skin, so we select our tenodesis reamer of the appropriate size nine millimeter. In this example, based on our intraosseous length of the spade tip, which is approximately 70. In this example, we'll ream to about 50mm in depth to allow for plenty of tensioning of the graft on the femoral side. Passing suture is shuttled for later graft passage. Turning our attention to the tibial MCL tunnel, we use the pezze tendons, which we've isolated here as our anatomic landmark, as well as the native superficial MCL as a landmark for our tunnel, which is usually 6 to 7cm distal to the joint line. Spade tip pin is inserted on the posterior half of the superficial MCL insertion and directed anterior and lateral bicortical. Once we've reached the far cortex, we pull back to measure our interosseous length. Spade tip pin is advanced out. The lateral skin care is taken to aim the spade tip pin anterior as it exits the lateral cortex, to avoid iatrogenic injury to the peroneal nerve. Tenodesis reamer seven millimeter in this example, is used to ream the tibial socket up to, but taking care to not perforate the lateral cortex. We now identify our pol tunnel more posterior and proximal. For this example, we'll use a spade tip and TightRope fixation in the setting of a concomitant PCL injury. Alternatively, a FastThread interference screw or SwiveLock as an interference screw in a socket can be utilized. This pin is aimed anterior and distal, approximately just distal to gerdy's tubercle Bio-Tenodesis reamer seven millimeters. In this example is reamed to create a socket of 30 to 40mm in depth. After final graft preparation, we've utilized our graft tubes and shuttled sutures for graft passage through our tunnels. We've lengthened our TightRope to allow for the intraosseous length of the femur, and we've marked our TightRope at 70mm, which is an estimate of the interosseous length that we gained from the spade tip pin. The InternalBrace suture stays with our graft as we pass this TightRope TightRope sutures are shuttled across in the typical fashion. As our mark gets to the aperture of the tunnel, we fill our button, come through with the leading sutures. We then pull on the trail tiger suture to flip the button on the far cortex, which is nice and seated. Once the button is flipped on the far cortex, which can be confirmed with fluoroscopy, tension is kept on the internal brace to keep the button flush with the lateral cortex As we tension the graft into the tunnel, we place about 20mm of graft into the tunnel initially. Clamp is placed deep to the peds, tendons just extracapsular for shuttling of the superficial MCL and internal brace. The pol limb of the graft is then shuttled posteriorly. The graft is shuttled posterior to the semimembranosus and then docked into its tibial tunnel. Again, fluoroscopy can be used to confirm the flipping of the button on the lateral cortex. Once the button is flipped, tension is kept on the graft to keep it flush with the lateral cortex. The knee is placed in full extension, and the pol graft is initially docked into the tibial tunnel, placing about 20mm of graft. To provide additional fixation for the deep MCL. Proximally, we're going to utilize a Self-punching 2.6 Knotless FiberTak anchor about 1 to 1.5 centimeters distal to the joint line. We've shuttled our repair stitch around the graft, but we'll save tensioning until we fixated it on the tibia. Tightrope sutures are shuttled into the tibial tunnel. Back tension is kept on the graft. Again utilizing the trail stitch and the TightRope for flipping of the button on the lateral cortex. As the graft is initially tensioned on the tibia, back tension is kept on the graft. The knee is placed in 20 to 30 degrees of flexion, and 20 to 30mm of graft is placed initially. The knee is placed in 20 to 30 degrees of flexion and utilizing our tensioning handles, the femoral side is retensioned. The knee is then cycled in a surgical setting. Valgus force is applied to take the creep out of the system. We then retention. We can then retention on the tibial side as well. The knee is placed in full extension and final tension is added to the tibial side of the pol graft. With the knee in 20 to 30 degrees of flexion and slight varus force. We then tension our FiberTak proximally for deep MCL fixation. Now we'll place our internal brace as augmentation. We did not place that through the knotless FiberTak proximally to avoid over tensioning. We'll make our mark, relax our tension and place it with a 5.5mm SwiveLock anchor. So we see our final construct with our tensioned superficial MCL, with proximal fixation and internal brace augmentation with a posterior oblique ligament reconstruction with all tight ropes. These patients can be allowed. Range of motion is tolerated, with progression of weight bearing as tolerated in extension, depending on concomitant pathology.

MCL and POL Reconstruction: FiberTag® TightRope® Fixation Using the InternalBrace™ Technique

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