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VID1-01435-en-US | B | GraftLink® ACL Reconstruction Using the InternalBrace™ Technique

Steve E. Jordan

Human

Adam Anz

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GraftLink® ACL Reconstruction Using the InternalBrace™ Technique

Today we're going to go over the graft prep for the BioACL at the Andrews Institute. We're working on a prospective study to evaluate the effectiveness in increasing maturation of an ACL. Autograft. We use a three by six thick amnion wrap. There's a notch to the upper left. It helps you keep it oriented, allowing you to keep the epithelial side up. Three centimeters allows us to cover the intra-articular segment of most ACLs and most knees perfectly, and the six allows you to get three wraps around it. We're going to show you how to do essentially a water tight wrap. We're going to do it with a dyed suture. We normally use a monocryl with thought to dyed suture would be easier to see. So what we do is place it in the center of a soft tissue graft. Sometimes on a BTB you may have to move it depending on the length of the graft. But here we're going to place it on the center and then moisten it. You moisten it and it allows it to work very well. This is a very workable tissue. Holds the suture very well. It looks like it might be friable, but it's actually very workable. And so we wrap it carefully like this. It usually takes about ten minutes on the back table to prepare this. And you see the way I wrapped it. The end comes around almost exactly the same spot you started on most graphs. What we start with is first is circumferential wraps around either end. And like I mentioned, this is usually a water type construct which makes it really nice. So we wrap it really good. Like so. I'm going to cut the end to make it a little easier. And tie this. You want to make sure you go through both layers. Get it tight as close to the end as you can get without having it come off. Thank you. Now we'll go to the other end and do the same thing. So if you're going to inject biologic solutions, we found this to be a nice construct to hold whatever solution you put it in where you want it next to the graft. What we're going to do is make a little running stitch along the free edge. I don't know if you can see that, but there's a little free edge there. We want to catch both. Tie quick knot and then run it. So now we're just going to run it up along the free edge. The goal is not to constrict the inner space too much, because we want any solution or fluids you put inside to be able to. Go all all throughout the the casing, so we don't want to compartmentalize it, if you will. This technique has allowed us to inject these and watch the whole rep swell up with with biology. Okay, we're almost done here. And we'll tie it off. And this is the completion of the amnion wrap for the BioACL. Again, I don't usually use a colored suture. I just thought it would be helpful today. And that's it. So you can see the center. The center, three centimeters is wrapped with an amnion wrap and a four row suture. Now that we have our graph prepared with the amnion wrap, we're going to load it with the internal brace. This is a double loaded TightRope RT. We're going to take off the larger of the two pull sutures to allow more room, leaving the other pull suture. I've loaded a graph parser in here. Now you take the ends toward the graph as you see we're doing here. Take them toward it. And then we're going to get the other side. Really not that hard. Using this little graph parser makes it pretty easy. Drop it down like so. Try to even up your ends. And not tangle anything. We'll do that. Like so. This completes the internal brace construct of the amnion wrapped soft tissue graft. And as you can see, loaded like this still has a good profile that's easily delivered. We have not had any problems delivering it with the standard technique with the TightRope TT. So here we have our amnion wrapped hamstring soft tissue construct with the FiberTape on the TightRope TT. We've drilled we've passed sutures and we're now going to deploy the femoral side so we can see where the TT button going into the tunnel. We've measured it at about 35. We've successfully deployed that. Now I'm going to hold tension on the graft while Adam shortens it into the tunnel usually about 15 to 20. Go ahead. You can see the wrap coming into place. And right at the edge. We've got 20 in the femoral tunnel, which is great. Now we're going to deploy the tibial side. And you see there it pops into the tibial side. As you can see the wrap covers the intra-articular portion. Tighten it up a little bit on the femur. I'm pulling down. We're going to get that a little bit closer. The notch plastic could have been a little bit bigger, but there you go. From tibia to femur with an internal brace which we're going to tighten separately like so. So we've got the graft in place. We're going to put the leg in extension and tighten the internal brace separately. So what you see here is I can tighten that and fix it to the tibia with a swivel lock or however you prefer. I prefer a SwiveLock. So I've got the internal brace. And then we'll flex to about 30 and tighten the abs TightRope on the tibia. And we're fixed. So the steps for injecting your biologic fluid underneath. First you need to dry the joint. So I'll typically use just any any type of suction device. I've cut my water off. And I'm just going to take all the fluid out of the knee. It'll kind of collapse down because of the suction, but once you let it off, then you'll have a nice little dry space in there. The other trick is to take a spinal needle and hook it up to suction. So this is an 18 gauge spinal needle. And I typically park that spinal needle down here near the lateral meniscal root. And then once it's parked down there, it kind of keeps everything sucked out. If you turn your eyes down, you can usually get to a nice dry spot and you want to get underneath the wrap and then just start injecting and see how it nice balloons up and creates almost a blood blister. Some of it will come out, but I think that the viscosity and the stickiness of the graft, as well as the injectable, keeps the majority of it where we want it. Typically you'll get two milliliters into your construct.

GraftLink® ACL Reconstruction Using the InternalBrace™ Technique

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