Knee

Procedure

Quadriceps tendon grafts offer unique benefits for cruciate ligament reconstruction, such as a predictably large diameter, low morbidity,1 and a preferable stiffness profile for knee ligament reconstruction.
The QuadPro™ tendon harvester is designed to harvest a quadriceps or patellar tendon graft using a minimally invasive technique.2-4 The sharp tip cores out an approximate cylindrical graft. The harvester's ergonomically designed handle features graduations on the clear shaft to allow visualization of approximate graft length during harvesting. Available in four sizes (8 mm to 11 mm), the QuadPro tendon harvester can accommodate each patient’s unique needs as well as the surgeon’s preference for graft diameter.
The FiberTag® TightRope® implant facilitates attachment of single-ended grafts, such as quadriceps tendon grafts, to the ACL TightRope RT and ABS implants. FiberTag suture is integrated into the TightRope implant for a strong, consistent connection between the suture and TightRope loop. A simplified suturing technique, along with innovative packaging and the GraftClamp graft preparation instrument, make preparing quadriceps tendon grafts faster and more reproducible than ever.
References
1. Arthrex, Inc. LA1-00100-EN_K. Naples, FL; 2021.
2. Xerogeanes JW, Mitchell PM, Karasev PA, Kolesov IA, Romine SE. Anatomic and morphological evaluation of the quadriceps tendon using 3-dimensional magnetic resonance imaging reconstruction: applications for anterior cruciate ligament autograft choice and procurement. Am J Sports Med. 2013;41(10):2392-2399. doi:10.1177/0363546513496626
3. Hadjicostas PT, Soucacos PN, Berger I, Koleganova N, Paessler HH. Comparative analysis of the morphologic structure of quadriceps and patellar tendon: a descriptive laboratory study. Arthroscopy. 2007;23(7):744-750. doi:10.1016/j.arthro.2007.01.032
4. Krebs N, Yaish A, O’Neill N. Anatomic evaluation of the quadriceps tendon in cadaveric specimens: application for anterior cruciate ligament reconstruction graft choice. SMRJ. 2019;4(1):7961. doi:10.51894/001c.7961

The QuadPro™ tendon harvester is the latest innovation for harvesting the quadriceps tendon using a minimally invasive technique. It was designed based on published anatomic studies and allows surgeons to safely and reproducibly harvest a graft of a desired length and diameter through a small incision and in a time-efficient manner.1-3 The system has the versatility to create grafts to meet the surgeon’s needs, whether the grafts be all soft tissue or with a bone block. The single-use design ensures sharpness, sterility, and convenience for every case.
References
1. Xerogeanes JW, Mitchell PM, Karasev PA, Kolesov IA, Romine SE. Anatomic and morphological evaluation of the quadriceps tendon using 3-dimensional magnetic resonance imaging reconstruction: applications for anterior cruciate ligament autograft choice and procurement. Am J Sports Med. 2013;41(10):2392-2399. doi:10.1177/0363546513496626
2. Hadjicostas PT, Soucacos PN, Berger I, Koleganova N, Paessler HH. Comparative analysis of the morphologic structure of quadriceps and patellar tendon: a descriptive laboratory study. Arthroscopy. 2007;23(7):744-750. doi:10.1016/j.arthro.2007.01.032
3. Krebs N, Yaish A, O’Neill N. Anatomic evaluation of the quadriceps tendon in cadaveric specimens: application for anterior cruciate ligament reconstruction graft choice. Spartan Med Res J. 2019;4(1)7961. doi:10.51894/001c.7961

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Human

QuadPro™ Tendon Harvester Graft Harvesting System

The quadriceps tendon was first described as an acceptable graft option for ACL reconstruction in 1979. Arthrex introduced a minimally invasive instrumentation set in 2014, enabling a safe, easy and more reproducible quadriceps tendon harvest between 2015 and 2019. Arthrex released the FiberLoop with FiberTag and FiberTag TightRope implants to further improve performance and efficiency. The QuadPro tendon harvester is the next evolution in this ACL reconstruction portfolio. The QuadPro clear handle enables direct visualization of the graft to ensure the appropriate length is harvested. Quadpro is also available in sizes eight millimeters through 11mm. Its sharp tip harvests a smooth cylindrical graft. This minimally invasive harvesting technique reduces graft site morbidity and overall procedure time. Once an appropriate length of tendon is stripped, the graft can be retrieved through the amputation window when the push rod is deployed. The sharp edge in the window will cut the graft. Make a small transverse incision, approximately one centimeter proximal to the patella. Dissect the subcutaneous fat and remove it proximally and distally in the incision. A key elevator can be used to clear soft tissue proximally and distally. A retractor can be used while an arthroscope is guided proximally to visualize the tendon. Identify the VMO and stay lateral to this landmark. Advance the scope proximally until the musculotendinous junction of the rectus femoris is visualized. Turn the lens of the scope toward the skin so the light can be seen through the skin. This is the proximal limit of the of the graft and marks the direction of the graft harvest mark the skin at this point. For reference, the width between incisions should correlate with the desired graft diameter. Make the longitudinal incisions and continue them distally toward the patella until contact is made with the bone. The surgeon should note that approximately two centimeters of tendon length needs to be dissected and released. Use a FiberLoop suture to place a tagging suture one centimeter from the end of the graft. This suture is used to maintain tension on the graft during tendon harvesting. The weight of the needle can be used to shuttle the tagging sutures through the cannulation of the QuadPro tendon harvester. Alternatively, a lasso wire can be used for shuttling the tagging suture. Advance the tendon into the tip of the harvester, ensuring the suture is not cut by the harvester tip. Keep steady, gentle tension on the suture and begin rotating the harvester using controlled quarter turns all in the same direction, directing the harvester toward the proximal mark on the skin. Once the desired graft length has been stripped, the QuadPro tendon harvester can be withdrawn from the incision and the graft can be retrieved through the graft cutting window. By grasping the tagging sutures, advance the QuadPro tendon harvester back into the incision. When the appropriate graft length is reached, insert the push rod into the harvester. Keep tension on the tagging suture, and advance the push rod forward to amputate the graft. The adjustable variable size, all in one FlipCutter three guide pin and reamer allows minimally invasive socket creation from the inside out. The FiberTag TightRope implant facilitates attaching single ended grafts to the ACL, TightRope, PT, and ABS implants. Fibertag suture is integrated into the TightRope implant for a strong connection between the suture and TightRope loop. A simplified suturing technique, along with innovative packaging and the new graft clamp graft preparation instrument, make preparing quadriceps tendon grafts faster and more reproducible.

John W. Xerogeanes, MD (Atlanta, GA), demonstrates a quadriceps tendon autograft ACL reconstruction using the QuadPro™ tendon harvester, FiberTag® TightRope® implants, and FiberTape® suture for the InternalBrace™ technique.
The InternalBrace surgical technique is intended only to augment the primary repair/reconstruction by expanding the area of tissue approximation during the healing period and is not intended as a replacement for the native ligament. The InternalBrace technique is for use during soft tissue-to-bone fixation procedures and is not cleared for bone-to-bone fixation.

QuadLink™ ACL Reconstruction Using the QuadPro™ Harvester and FiberTag® TightRope® Implants

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QuadPro™ Tendon Harvester Surgical Technique

The FiberTag® TightRope® implant offers improved performance and reduces quadriceps tendon graft preparation time.1 A FiberTag suture is prestitched onto a TightRope II implant and the GraftClamp instrument is used to hold the tendon and suture card while the graft is prepared.&nbsp;
 
Reference 
1. Arthrex, Inc. Data on file (APT-04275). Naples, FL; 2019.

FiberTag® TightRope® II Graft Preparation

The FiberTag TightRope two implant builds on Arthrex. S legacy of innovation in ACL graft fixation technology by adding optimized features to the revolutionary FiberTag TightRope implant design. The flat tape loop and tensioning strands provide improved strength, feel, and handling. The redesigned cortical button includes a proprietary knotless fifth locking mechanism for increased strength and resistance to cyclic displacement, and allows for precise incremental tensioning of the construct after final fixation. The FiberTag TightRope two implant is available with a preloaded FiberTape suture for the internal brace technique, proven in peer reviewed research to be associated with less pain, improved patient reported outcomes, and a faster and higher rate of return to pre-injury level of activity. Alternatively, the FiberTag TightRope two implant is available preloaded with an additional flipping suture for optimized cortical button deployment. New, shorter locking splices create a shorter minimum loop length to maximize the amount of graft in the socket. A straight tapered needle makes graft suturing smooth and effortless. And an enhanced SutureCast design improves suture management during implant assembly. Mark the graft circumferentially at the desired length of stitching. Load the FiberTag TightRope two SutureCast onto the graft clamp instrument. It's important to fully seat the card into the slot in the jaw of the instrument. The FiberTag implant can be pushed onto the tooth of the graft clamp for further stabilization. Clamp the graft clamp approximately two millimeters from the end of the graft. Pass the improved tapered needle at the marking to provisionally extend the FiberTag implant along the graft. Use the standard FiberLoop technique with two SpeedWhip stitches, working toward the suture card and ensuring the FiberTag implant is captured with each needle pass. After the two SpeedWhip stitches are performed, insert the Insert the needle through the slot in the SutureCast, ensuring the needle passes over the TightRope loop. Place two additional SpeedWhip stitches working back down the FiberTak implant, forming a locking style stitch. Pass the needle into the tissue beyond the end of the FiberTag implant. Cut one suture loop just below the suture. Splice near the needle, ensuring the needle is still attached to the opposite end. Wrap the suture limbs around the graft and tie them securely. Then cut the suture without the needle. Use the needle to bury the knot within the graft. Cut the remaining suture limb flush with the graft. Remove the FiberTag TightRope two suture card from the graft clamp and unclip the remaining sutures from the suture card. Prepare the opposite end of the graft with a FiberTag TightRope two ABS implant in a similar fashion.

Jason M. Scopp, MD (Salisbury, MD), discusses recent innovations in QuadLink™ ACL reconstruction.

QuadLink™ ACL Reconstruction Using FiberTag® TightRope® Implant and FlipCutter® III Drill

Hi, my name is Doctor Jason Skop and today I'm going to talk about innovations in QuadLink ACL reconstruction. Our patient is a 22 year old male lacrosse player who presented with an ACL tear during the diagnostic arthroscopy. He was found to have a repairable posterior horn medial meniscus tear. This was repaired with two meniscus since two implants in a vertical mattress fashion, giving us a stable construct, as you can see here. We then turn our attention to the quad harvest. A two centimeter incision was made at the superior pole of the patella. The section was carried down through the para tenon, which was swept medially, laterally and proximally. Then a ten millimeter double blade knife was used to harvest a central slip of the quadriceps tendon to a distance of 65mm. The graph was then removed from the knee and placed on the back table for preparation. Using the FiberTag TightRope implant, we use an RT on the femoral side and an ABS on the tibial side. Two SpeedWhip sutures were passed proximally through the TightRope and then two passes distally to complete our femoral preparation. This was performed similarly on the tibial side. An internal brace was then incorporated into the femoral end of the graft. We then took the graft compression tubes to take our construct, which was now 10.5mm, and compress it down to a graft of 9.5mm. We then turn our attention back to the knee to begin our tunnel preparation using the femoral six nine guide. We drilled our FlipCutter three and visualized its entrance into the joint. Once the FlipCutter three device was visualized, we activated it and chose our tunnel size to correlate with a 9.5mm socket. We chose a 9.5 socket here, even though the graph was originally 10.5mm. That compression of the graft during graph preparation allows for graft re-expansion later on to improve our fill of our socket. This is also performed on the tibial side. Once the FlipCutter has been activated, our femoral tunnel is created and a shaver is inserted to remove any loose debris prior to passing our FiberStick. The tibial tunnel is created in a similar fashion. The advantage of the FlipCutter three is if my graft size on the tibial end does not match the graph size of my femoral end, I do not need to open up a second FlipCutter device. I am able to simply dial down or dial up to improve my accuracy during tibial tunnel creation. Our graft is passed and our internal brace here is visualized on the posterior aspect of the graft. And here are the patient's final post-operative radiographs. Thank you.

QuadLink™ Graft Preparation Using the FiberTag® TightRope® II Implant

Quad Tendon Autograft ACL Reconstruction

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Arthrex offers a comprehensive selection of fixation devices for a variety of bone-patellar tendon-bone (BTB) graft techniques. These options include adjustable, continuous-loop suspensory fixation, and interference screws in a variety of materials. The TightRope® implant, which has been used in 2 million procedures globally,1 was designed to simplify ACL reconstruction and facilitate advanced techniques, such as the GraftLink® technique. BioComposite FastThread™ interference screws, which are composed of time-tested material with more than a decade of clinical success and implantation, allow for faster screw insertion and better graft protection.2
References
1. Arthrex, Inc. Data on file (sales data as of September 18, 2018). Naples, FL; 2018.
2. Arthrex, Inc. LA1-0199-EN_E. Naples, FL; 2018.
Please note that certain bio (PLLA) anchors and screws are not available for sale in EMEA.

This animation demonstrates a BTB ACL reconstruction using the TightRope® II BTB implant with FiberTape® suture for the InternalBrace™ technique, BioComposite FastThread™ interference screw, FlipCutter® III drill, and 4.75 SwiveLock® anchor for ACL backup fixation.
The InternalBrace surgical technique is intended only to augment the primary repair/reconstruction by expanding the area of tissue approximation during the healing period and is not intended as a replacement for the native ligament. The InternalBrace technique is for use during soft tissue-to-bone fixation procedures and is not cleared for bone-to-bone fixation.

BTB ACL Reconstruction With BTB TightRope® Implant and FastThread™ Interference Screw

The femoral socket is prepared in a retrograde fashion using the FlipCutter three reamer and side release RetroConstruction drill guide handle. The adjustable all in one FlipCutter three retrograde drill can accommodate varying tunnel sizes from 6 to 12mm, including half sizes. The guide is placed into the joint and the FlipCutter drill sleeve is inserted down to bone. The FlipCutter three is then drilled into the joint, and the side release drill guide handle is removed. The stepped drill sleeve is then melted into the bone. The FlipCutter three size wheel is used to deploy the tip to the appropriate size, and a socket is reamed to the desired depth. After creating the socket, turn the size wheel back to 3.5 and remove it from the joint while keeping the drill sleeve in place. A FiberSnare suture is then passed through the drill sleeve and retrieved through the tibial tunnel. The revised, streamlined BTB TightRope two preparation card is intuitive and steps are labeled for simple implant assembly. Load the blue passing suture and white tensioning strands into the FiberSnare, and then pull through the femur, leaving FiberTape InternalBrace sutures out of the tibia. Pull the sutures together to advance the button, while maintaining counter tension on the FiberTape and traction sutures. When the femoral bone block is visible in the joint, stop advancing the graft and align the bone block with the femoral tunnel using a grasper or a probe to advance the graft. Pull the tensioning strands one at a time, alternating approximately two centimeters on each side, while maintaining distal counter tension on the graft and InternalBrace sutures. Once the graft is seated, pull firmly back on the graft to check fixation before fixing and tensioning the graft. The internal brace is anchored using a Biocomposite SwiveLock ACL backup fixation system. Using the spade tip drill followed by the 5.2mm tap. The internal brace FiberTape are placed into the eyelet and with the knee in full extension, the SwiveLock is screwed into the drilled hole. The appropriate sized biocomposite FastThread interference screw is selected, and a 1.1mm guide wire is then inserted in the tibial tunnel between the tibial bone block and tunnel wall. The appropriate size tap is then inserted over the guide wire and driven to a depth that approximates the screw length. A FastThread interference screw can then be implanted over the guide wire on the free edge of the bone, plug away from the tendon, insert the screw to the appropriate depth and if necessary, release the slap driver handle to remove the driver. Check fixation of the graft and remove the guide wire. The knee can be tested through a range of motion and with the knee and full extension. The BTB TightRope two can be retensioned to remove any slack in the graft construct.

Justin J. Mitchell, MD (La Crosse, WI), demonstrates a bone-patellar tendon-bone (BTB) ACL reconstruction using FiberTape® suture for the InternalBrace™ technique. Dr. Mitchell explains how to properly assemble the new BTB TightRope® II implant to the graft, fixates the tibial side of the graft with a BioComposite FastThread™ interference screw, and fixates the FiberTape suture for the InternalBrace technique with the ACL Backup Kit using a 4.75 mm BioComposite SwiveLock® anchor.
The InternalBrace surgical technique is intended only to augment the primary repair/reconstruction by expanding the area of tissue approximation during the healing period and is not intended as a replacement for the native ligament. The InternalBrace technique is for use during soft tissue-to-bone fixation procedures and is not cleared for bone-to-bone fixation.

BTB ACL Reconstruction Using the BTB TightRope® II Implant and InternalBrace™ Technique

We're going to be performing an ACL reconstruction utilizing a Bone-tendon-bone autograft with our BTB ACL TightRope two with the associated internal brace. The TightRope two with the internal brace is prepackaged on this card and gives you step by step instructions on how to complete the procedure. The first thing we're going to do is take our needle out of the number one slot, and pass that through our previously drilled hole in the femoral bone block. After passing our suture, we're going to cut the needle off and we're going to transition to step number two, taking off the free suture which will unravel. And then the free end of this suture is going to be passed through our loop. So after we've passed it through the loop within the bone block, we're going to take the free end of our suture and pass it through the wire loop on the card. One of the tricks here is we can actually fold this over and pinch it so that it's easier to pass. So now that we've got that suture pass through the wire, we're going to hold our pinched end here like I talked about. And essentially we're going to pull this tab out which will allow us to pass our suture. And one of the tricks here is just to kind of hold the end of the card gives you some resistance so you can pull that right through. Once we've got our suture pass through the mechanism we can actually flip our card over. We're going to pick up our trapdoor tab and pinch our side tabs like this, which is going to allow all of the sutures just to come straight off like that. Once we've got all of our sutures off the back of the card, we're going to take the card, and at the bottom everything just opens up, exposing the internal aspect of the card and the button. Once we've got the card open, we can see our button, and we're going to pull our button straight through the card, which will bring all of our remaining sutures out of the card. We can see here, now that we've got our sutures separated, our internal brace strand is coming this way, and the free end of end of our previously passed suture is right here, which is going to allow us even up the TightRope tensioning strands. Now that we've got our ACL tensioning strands, even we can shuttle the sutures through the bone block to ensure ease of passage when we're tightening our final construct. In the event that anything should happen on the tibial side or any of these sutures should break, what I like to do is put a rescue stitch right at the junction of the bone tendon interface with a FiberWire suture, so that we have a rescue suture as we pull through the tibia, just in case anything should happen. So we've got our graph prepared. We've got our tunnels drilled. You can actually see our passing suture coming through the femoral tunnel into the tibial tunnel. We've got a full socket in the tibia, because we're going to use a FastThread screw to secure the tibial side. And now we're going to pass our BTB TightRope two up through the tibial tunnel and secure it over the lateral side of the femur. So you can see here our sutures are passing coming through the femoral tunnel. So now we see our button being pulled in. We can see it transitioning to the to the femoral socket. And I'm actually going to switch to a medial view so I can see the button go through the tunnel and flip on the lateral cortex. You can actually see the button coming right into the femoral tunnel going into the aperture of the femoral tunnel. We're going to pass that button through the hole onto the lateral cortex. And what the assistant is going to do is actually pull tension on the internal brace strands, which is going to help us keep tension on the button so that it will flip over the lateral cortex. So now we feel that we've got the button flipped. We're going to give a little tension on the sutures through the tibial tunnel. You can see we're giving a little tension there. And we've got that button nicely flipped against the lateral cortex. So you can see now we've got our sutures passed through the tibial tunnel and into the femoral tunnel. The nice part about this is I was able to use the FlipCutter to create the femoral tunnel. We don't have to be parallel with our portals in this situation. And so the nice part about the FlipCutter is it gives a very smooth aperture and allows for easy passage of our sutures when we're pulling our bone block in. Now we're going to have our button against the lateral femoral cortex, and it's going to going to allow for circumferential fixation of our graft and our bone block, which is different from having a screw fixation, which actually takes a little bit of the surface area away from the bone block. So now we're going to start pulling this in and putting our bone block into the femoral tunnel. So one of the things you can do is this is coming in is give a little bit of slack on these sutures using a probe. And you can see our bone blocks starting to come in. This is allowing us to get things in an appropriate trajectory. So I'm using our KingFisher here to direct our bone block into the correct position so that it will easily slide into the femoral tunnel. So now as you can see, we've got our graft all the way into the femoral tunnel. You can see our purple mark right at the edge there. So we've got our bone block right to the aperture of the femoral tunnel. We've got the remainder of our graft in here. And you can see down in our tibial tunnel we are just nearing the purple mark. So the edge of our bone block you can see our rescue suture there. So we've got this very nicely past. And now we're going to work on the tibial side of the graft. So now that we've got everything past we're turning to our tibial side and we and we can actually see our InternalBrace sutures coming out the tibial tunnel. Right here. And what we're going to do is independently fixate our InternalBrace sutures just distal to the aperture of the tibial tunnel. So the first thing we're going to do is create our drill pilot hole. And at this point, the knee is in full extension. So now that we've drilled our pilot hole, we've got our new 5.2mm tap which comes in the ACL backup kit. The nice part about this tap is that the thread pitch is perfectly aligned to the 4.75mm SwiveLock, and using this allows for placement of that swivel lock in harder tibial bone and can accommodate an associated FiberTape. So we're tapping here using our 5.2mm tap. So with our tap in place, we've already preloaded our 4.75mm SwiveLock. And this helps make sure that we do not lose our pilot hole. We've now got our SwiveLock secured against the anteromedial tibia, such that our internal brace is independently fixed outside of our bone block. And actually, this FiberTape is actually on the back side of the bone block so that when we put in our screw, it's not abrading against the screw. [00:06:29] Yeah. Yeah. Sorry. Yeah. Good. So now that we've got our internal brace fixed, we are keeping longitudinal tension on our sutures that are within the tibial bone block. You can see our rescue stitch is independently clasped on this side, just in case we need it. And I'm going to insert our guidewire right over the superior aspect or the anterior aspect of the bone block. We're going to insert our tap over the anterior aspect of the bone block to allow for passage of our FastThread screw. I can see the bone block right at the aperture of our tibial tunnel. So I know we've got good graft tunnel match. Now that our tapping is complete, we're going to insert our FastThread bio composite screw over the anterior aspect of the graft in line with the tunnel. And you can actually hear that good fixation there. So one of the really nice things about this screwdriver is that it actually has a self slap hammer mechanism so that you can unlock the screwdriver, back it off, and actually pull the screwdriver off easily. As we know, these screwdrivers can sometimes get stuck in these screws, and it's easy to just back it out with that self slap hammer mechanism. So the really nice part about using the TightRope two system is that after we've fixed our distal tunnels, we can actually retension the femur to make sure we've got all the creep out of the graft. So if we pull on our femoral sutures, we should be able to get a little bit extra out of the tensioning system. So with our knee extension, we're just going to pull a little bit of creep out of this system. And you can see that graph moving ever so slightly taking all the remaining creep out of the graft. And in the end we've got a very nicely situated bone-tendon-bone graft appropriate tension. And our reconstruction is complete.

Imaging and Resection

James E. Voos, MD (Cleveland, OH), demonstrates an ACL reconstruction using the Synergy Vision™ imaging system and the Pano™ scope.

ACL Reconstruction Using the Synergy Vision™ Imaging System

Hi, I'm Doctor James Voss from University Hospitals Cleveland. Today we're going to talk about using the SynergyRF vision NanoScope switching from 30 to 70 degree visualization in both a diagnostic arthroscopy. Also, in referencing our ACL reconstruction, allowing us to visualize our ACL footprints for precise tunnel placement. The NanoScope allows for the ease of navigation, transitioning from the 30 to 70 degree arthroscope without having to change the lens, allowing us to be more efficient and more precise in tunnel placement. We'll start with our standard diagnostic arthroscopy of the knee, beginning in the patellofemoral joint with our standard 30 degree view, being able to visualize both our patella and trochlea. The unique part of the SynergyION NanoScope is switching to our NanoScope view, allowing for that broader visualization of the entire patellofemoral articulation. Looking for articular cartilage lesions and in cases of patella instability, being able to assess the depth of the Of the trochlea. The medial facet. Patella chondral injuries as well as the lateral trochlea. Injuries all in one view, giving you a much more comprehensive view of the level of pathology and easily transitioning to the 70 degree and the 30 degree scope allows you to maneuver around the joint for your typical diagnostic arthroscopy. As we continue our diagnostic scope, we get our standard 30 degree view by moving to our NanoScope allows us to get a much more global view of the entire condyle assessing for articular cartilage lesions. Again, moving over to our notch. And we'll go back to our standard 30 degree scope, again showing how easy it is to transition with one push of a button going into our lateral compartment, being able to assess the route. And again, getting that much more global view of the articular cartilage surfaces and global view of the meniscus. Coming over to our medial compartment, again, able to visualize with our standard 30 degree scope and without having to change again. Moving to that Pano view, assessing the entire articular cartilage surface, as well as being able to see back towards the root. One of the most versatile applications of the vision, NanoScope, is assessing the ACL footprints, both on the femur and on the tibia. Here we have our standard 30 degree arthroscopic view showing our tibial footprint and looking around the corner to our femoral footprint. Typically, at this point in the case, we would switch to a 70 degree arthroscope, which takes some additional time, as well as the additional needing to open a 70 degree lens here, just with the push of a button switching from the 30 to the. The Pano view allows you to really visualize the entire ACL footprint. Your 70 degree scope brings you around even further. So that 30 degree view all the way over here where you can't quite visualize your footprint, allows you to have that direct visualization. Now you have much more accurate footprint assessment, much more accurate tunnel placement. You're able to visualize the back wall as well as the entire anatomy of the ACL. So we'll show more of that here later as we're drilling our tunnels. And as we've published previously utilizing the 70 degree scope. And now the NanoScope view allows us, as we're drilling our femoral ACL tunnel again, to have accurate tunnel placement as well as accurate depth, being able to measure both the front and the back of our tunnel to assure the appropriate depth. So we don't have any bone plug and graft mismatch. In addition, coming down to the tibial footprint, we'll go back to our standard 30 degree view, which we typically see. And often it's hard to see ACL material graft material flipped over here in front of the meniscal ligament. Now with our NanoScope allows for that easy view all the way in front to be able to see the anterior horn of our lateral meniscus and any ACL material that may be flipped forward that can cause a Cyclops lesion. This also allows for that full assessment of very accurate tunnel placement, as we place our guide to ensure that we're very accurate, again with our 70 degree scope having that similar view. If we look again, our angular view with our 30 degree scope doesn't quite give us that full perspective. Now with our NanoScope allows again visualizing the entire footprint much more accurate placement of our tibial guide. Right here we're preparing to do our notch plasty again with our standard 30 degree view, where we would prepare our notch plasty in efforts to see the back wall. And with the standard 30 degree scope, there is often the need to do a larger notch plasty than you would otherwise plan to do in order to see the back wall. By utilizing the NanoScope and the 70 degree view, now we can see the See the entire notch here, the wall on Foss allowing us to take the appropriate amount of bone. So now we can protect the ACL graft from impingement, but avoid excessive bone resection. Now, utilizing the shaver here allows us to continue the visualization without having the excessive suction with the fat pad collapsing on you and again with the. Utilizing the NanoScope allows us to be much more precise with our notch plasty again, taking just the appropriate amount of bone here to pass the graft without impingement. Great. So again, we can see all the way to the back very easily, having a nice smooth notch from front to back. And again, if we sit here with our NanoScope, let's go back to our 30. We show the difference of how you're looking down the wall versus straight at the wall. You have a much more precise view, right? Here we are after removing our ACL to breeding back to our tibial and femoral stumps, our notch plasty is complete. This is one of the areas where the NanoScope has the most versatility in femoral tunnel placement. And here with the typical 30 degree view as we're feeling around the back wall, attempting to make that 70 degree or that seven millimeter measurement here off the back wall, it is very challenging with our depth perception to have accurate tunnel placement. So one of our most common errors in ACL failure is poor tunnel or improper tunnel placement. So using the NanoScope to increase that accuracy can increase the outcomes of our ACL reconstructions. Now by switching to our NanoScope allows us to have a much more accurate visualization and depth perception from our back wall, measuring those seven millimeters anterior to get our most accurate tunnel placement to avoid that tunnel mismatch. One of our other key benefits of using the NanoScope. Now that we can visualize the footprint accurately, it avoids the need to have to hyper flex the knee during the surgery, which can limit your visualization. Now that we have our ability to see the entire footprint utilizing our flexible reamer, now we can place our tunnel accurately, leaving our knee at that 90 degree position, which frees up hands and space in the operating room. So now we can drill our tunnel here much more accurately. Again, looking right at the face of the footprint here. And again, with the NanoScope, just with a slight rotation of the hand, gives you much more global view of that pin entry. Again, visualizing your back wall throughout the entire process. But here now with our pin placement, as we've published previously, the difference from the 30 to 70 degree arthroscope here now, using our NanoScope allows us to look from the top down, viewing our pin placement, getting very accurate measurements. And as we place our reamer, we'll have even more accurate measurements as to the front and back positions of the tunnel. An additional advantage of the NanoScope is being able to see the reamer pass through the medial portal and past the medial femoral condyle, to avoid any scuffing or injury to the medial femoral condyle, again allowing that increased visualization to avoid any iatrogenic injury. Now, as we have the reamer in again, a very versatile and one of the most advantageous parts of using the NanoScope is as we drill our femoral tunnel. We're typically referencing here distally to get our measurement. As we've recently published, with our utilization of a 70 degree scope and the top down view, the NanoScope allows us to measure not only the front of our tunnel, but the back of our tunnel. And as recent studies have shown, coming through the medial portal, the tunnel entry can be oblique or an ellipse direction where your distal portion of your tunnel may measure deeper than the posterior portion of your tunnel. So measuring off of the back wall gives you a much more accurate depth of your tunnel. That way, your bone plug you avoid any tunnel and bone plug mismatch. So unique advantage of the NanoScope is able to visualize the posterior portion or the deep portion of your tunnel, so you have accurate depth. Utilizing our Pano NanoScope again, our typical view straight on being able to look over the top and measure off the back wall. Now as we continue to insert our reamer, we know exactly the depth, both the distal and posterior ports, portions of our femoral tunnel so we can continue on. Here's a nice example of being able to measure. Our front portion of the wall appears to be about 21, whereas the back portion of the wall is that 19. So if we really want accurate placement, we can measure off the back. We'll go just a few few more millimeters getting there to 22. Perfect. Now we know the back wall is that 22. Again, for much more accurate tunnel placement. This is very important in our primary ACLs, but even more important in our revision surgeries where tunnel depth and protecting the back walls is most important. Here we are preparing our tibial tunnel guide pin placement. We've cleaned off the ACL footprint with our typical 30 degree arthroscope view utilizing our references of the Of the tibial spines, the anterior horn of the lateral meniscus, and the intra meniscal ligament. So our typical 30 degree view gives us that slightly oblique view. By switching to our NanoScope gives us a much broader view, allowing us to more easily visualize all of those frames of references, also allowing for better depth perception and placement of our guide. Again, seeing in one view our entire meniscal ligament, our anterior horn of our lateral meniscus and our tibial spines, allowing for us to triangulate for a very accurate guide pin placement. In addition, it allows us to look directly at the pin coming in with that bird's eye view versus a more oblique shot, again confirming our more accurate pin placement. Our tibial tunnel has been prepared with a ten millimeter cylindrical reamer. Here's our typical 30 degree view where we can see the tunnel in particularly the back wall. It's a little bit harder to see that interior wall to see circumferentially. By switching to our NanoScope now allows us to visualize the tunnel Circumferentially 360 degree view. This is important in our ACL tunnel drilling. If you're using an all-inside technique to get a sense of the depth of your tunnel. In a revision setting where you're looking for circumferential bleeding, bone in removal of prior graft material, or assessing where cystic formation or tunnel widening may be, it also allows, in those circumstances, utilizing a bone dowel or needing accurate assessment of tunnel depth for us to visualize very accurately and all planes circumferentially the depth of your tunnel. Here's our standard 30 degree view of passing our button for our ACL TightRope again 30 degree view. Attempting to look up the tunnel to watch the button flip by switching to the NanoScope scope allows you to look directly up the tunnel. Circumferential view, watching the button pass up the tunnel and allowing for that safe visualization of flipping of the femoral button. As we prepare to pass our bone plug, now having that direct visualization of the button flipping as well as your tactile feed pulling back to know that your button is flipped. So dual confirmation of both. Direct visualization of the flipping of the button, as well as your tactile pulling back to assure that the button has flipped on the far cortex. And in particular, referencing our study before from the 30 to 70 degree scope. Now we can see the back wall assure our bone plug is flush with the back wall. Very accurate bone plug placement. Okay, now we're in our Pano NanoScope mode, where we can see our entire ACL construct from anterior to our tibia to make sure that there is No ACL, stump or debris all the way up our tunnel. Now we've tensioned our our internal brace here posteriorly so we're a nice, good tension. Our GraftNet tension. And we're going to refine our tensioning of the graft here in extension. So we'll we've done our cycling. We'll do our final tensioning here in full extension. And again with the NanoScope allowing us to look all the way up the tunnel, getting a full fine view. Excellent. Seeing that last little bit of tension here in our graft. Again, in one view, being able to visualize from our tibial tunnel all the way up into our femoral tunnel, accessing that nice tension here in extension, completing our ACL reconstruction.

BTB TightRope® II Implant

This animation highlights the ACL TightRope® implant’s successful clinical history,1 introduces the TightRope II implant, and explains the new implant’s unique features and benefits.
1. Arthrex, Inc. Data on file (as of July 10, 2018). Naples, FL; 2018.

Introduction to the TightRope® II Implant

The ACL. Tightrope implant revolutionized suspensory graft fixation by allowing intraoperative adjustability of the graft position with a single implant, eliminating the need for multiple size options. With an innovative design compatible with several graft types and socket creation techniques, the implants reliability has been proven with a history of nearly 2 million implantations and supported in hundreds of published studies. Newly redesigned, the ACL TightRope two implant represents the next evolution in suspensory graft fixation for additional strength. The TightRope two loop is constructed of a flat tape, creating a broader suture graft interface. Flat tensioning strands provide improved handling during tensioning. Engineered for precise graft tensioning, the TightRope two implant allows for incremental tensioning of the construct after final fixation. The redesigned cortical button now incorporates a proprietary knotless fifth locking mechanism for increased strength and resistance to cyclic displacement. Versatile and innovative. The TightRope two implant is compatible with multiple graft options and all existing socket preparation devices, including the FlipCutter three drill, as well as flexible and low profile reaming systems. The TightRope two implant facilitates improved biomechanics and circumferential graft to bone healing in both femoral and tibial sockets, with significantly improved graft integration and less tunnel widening compared to screw fixation. The preparation card for the BTB TightRope two implant is streamlined for a faster, easier and more intuitive graft assembly. Tightrope two implants are available in PT and BTB configurations, preloaded with an additional flipping suture or with an included internal brace implant, as well as ABS and open ABS options. The Arthrex TightRope two is another example of Arthrex continued commitment to product innovation and helping surgeons treat their patients better.

FastThread™ Interference Screws A New Turn in ACL Fixation

James P. Bradley, MD (Pittsburgh, PA), demonstrates a BTB ACL reconstruction using BioComposite FastThread™ interference screws and the FiberTape® button for the InternalBrace™ technique.&nbsp;
The InternalBrace surgical technique is intended only to augment the primary repair/reconstruction by expanding the area of tissue approximation during the healing period and is not intended as a replacement for the native ligament. The InternalBrace technique is for use during soft tissue-to-bone fixation procedures and is not cleared for bone-to-bone fixation.&nbsp;

BTB ACL Reconstruction Using BioComposite FastThread™ Interference Screws and the FiberTape® Button for the InternalBrace™ Technique

Good morning. I'm Jim Bradley from Pittsburgh, Pennsylvania. I'm going to talk to you about the internal brace ligament augmentation button that can be used with either allografts or autographs. So we've already made our tunnels for the BTB ACL. We're going to use a FiberSnare that you can put through the needle, which we're going to pass through the tibia and the femur, allowing you to pass both the sutures from the BTB and the internal brace at one time. So we push this through. We're going to pull it out and capture the FiberSnare. So we're going to grab the FiberSnare out of the knee, bring it out through the tibial tunnel. So we're going to load the BTB passing sutures and the internal brace passing sutures through the through the FiberSnare both at the same time. So now you can obviously see that outside our tibia we have our BTB graft and our internal brace augmentation device through the same time. So now we're going to take the blue number five and independently pass that first with our internal brace augmentation device. Now we have to flip that. Now that it is set just by toggling those sutures you can set the device. Now it's set I can't pull it out anymore. So now we're going to bring the graft into the femur and fix only the femoral end. Perhaps in there's the hole. The internal brace is behind the bone. Patellar tendon. Bone graft. So now we're going to tap for the FastThread screws. So this is a seven by 20. Fastthread ACL screw. Just run it right up after you've tapped and run it right over your guidewire and engage the femoral foam plug of the BTB graft. Sometimes it gets stuck like that. So what you actually can do is you can unhinge it here, and you can use this almost like a slap hammer to get this off the screw like that, rather than try to pound it out. There's the screw. The internal brace is behind the construct where I want it. And now, in full extension, we're going to fix the internal brace first in full extension, and then we'll fix the tibial side of the BTB graft. What we have here is a 4.75 drill bit for the swivel lock. You want to go right above the Pez. Remember the Pez is sitting right there. So and if you just get a little bit above it there's really good cortical bone right there. And you must tap this bone because it's really hard. This is a 5.2mm tap from the ACL backup kit. Put your SwiveLock at the orifice. Full extension. You tap it in. The reason you use A52 tap is because you have to accommodate these two fiber tapes. I put it flush with the cortex, and once I feel that it's flush with the cortex, I then remove the swivel lock. And now you can cut your fiber tape. And now it's time to fixate your graft. So once again we're going to tap for our FastThread ACL screws. The leg based on the patients whether they're a hyperextended or they're not. We typically do it in full extension also, especially if they're hyper extenders. So this is my biocomposite FastThread interference screw for ACL bone BTB fixation. So once again one of the unique features of this once you get it to the cortex is you can use this as a slap hammer. It'll slap it out for you so you don't have to use your mallet. So this is our full internally brazed BTB construct. And you notice that the internal brace is posterior to the graft. Utmost importance. You always fix the internal brace in full extension. So my post-op protocol with no involvement of the Menisci is this patient is in a brace, their full weight bearing on crutches. The crutches end the end of the first week. The brace ends at the end of the fourth week. They're on a bike by the sixth week, and they're jogging by three months is the typical protocol.

BTB Autograft ACL Reconstruction 

Arthrex offers the most advanced techniques and instruments for hamstring harvesting and preparation for ACL reconstruction. A reproducible harvest can be performed through a traditional anterior or posterior approach using the minimally invasive hamstring harvest technique and specialized tendon strippers.
The GraftLink®&nbsp;technique provides an anatomic, minimally invasive, and reproducible ACL reconstruction procedure. When used in combination with anatomic guides, the FlipCutter® III drill allows independent femoral and tibial "retrodrilling" to create sockets while maintaining the cortices to maximize fixation. Femoral and tibial TightRope® II implants, with a proprietary 5-point locking system, make the GraftLink technique the most reproducible ACL reconstruction available.
Anatomic: Independent tibial and femoral socket preparation with FlipCutter III reamer and/or low-profile reamers facilitate unconstrained placement of the ACL graft.
Minimally Invasive: Socket preparation with the FlipCutter III reamer limits soft-tissue dissection and helps preserve bone and periosteum.
Reproducible: The GraftPro® graft prep system simplifies graft preparation; the tapered graft and adjustable ACL TightRope II buttons facilitate graft passing, fine tuning of graft depth, and graft tensioning from the femoral and tibial sides.

J. Lee Pace, MD (Plano, TX), presents his technique, tips, and pearls for graft preparation using the GraftLink® system for all-inside ACL reconstruction with the TightRope® II implant and SutureTape.

Graft Preparation Using the GraftLink® Technique With the ACL TightRope® II Implant and SutureTape

Hello, everybody. Lee Pace here from Plano, Texas. I'm going to take a few minutes today to go over some tips and pearls for graph preparation for a quadruple semitendinosus GraftLink using the TightRope two implants, as well as some new SutureTape loop options. We have our Semitendinosus here on our GraftPro. We have already cut it down to size. This is going to be about a ten millimeter graph once it's quadrupled over. So we've already taken care of. That first step we want to do is we want to make sure that this is of the appropriate length. What we're going to be shooting for is ultimately a length of about 70mm, so that we can effectively have enough collagen in our tunnels and also accommodate for the tightropes, which will effectively be just inside either end of the loop there. And that'll give us the construct that we want. So what we're going to start off doing is we're going to check our length, our quadrupled length. We can take the graph and we can double it over just like this. And then we can take just a simple suture, put it in the middle, fold it over again. And then we can just put just put a little bit of tension on this. So we have the one end of the graph at zero, and the other end is looking right around 80 or just a little bit beyond that. So we're going to do is we're going to shorten this a little bit and then just kind of go back and forth until we have the length that we want. So I'll unfold this. Lay this out as far as which side we're going to shorten. We're probably going to take a little bit off of this side here because this is a little bit smaller. Okay. So what we're going to do is we're going to cut this off. What I'm going to do is we want to get the overall graph length to be somewhere around two 7280 when it quadruples over. That'll give us about the 70 millimeter length. We're going to cut this right here at about 40 just to be conservative to begin with. And that looks like that'll work right there. We'll give that a shot. So we'll do the same thing. Fold it over give it a tug. You can see now with it stretched out that that's going to be just right around 70. So that looks pretty perfect right there. So that should work. So now that we know we like our length, we're going to double check our diameter. So we make sure we drill the appropriately sized tunnel. So we have this graph looped over the suture. We're going to bring it up to the sizing block just like this. Pull it through. You can see that pretty easily goes through a ten just like that. So we have our size. Our diameter is the same. We've got our length. And so now we can go ahead and start whip stitching this and applying the tight ropes. So what we've got now is we're going to basically take this graft. And we are going to place it through our TightRope loops to create the quadrupled GraftLink. What we've done here is we have our T TightRope here that has the internal brace on it, and we have our abs TightRope two on this side. We've basically set these loops up to be 70mm apart, which is the length that we want our GraftLink to be. We're going to start on the ABS side, the tibial side. We're going to pull the graft up through. We're going to even it out like this. Now we're going to take each of these two ends here. And we're going to pass one from top down and one from bottom up through the femoral Role. Tightrope. And then we can clamp just like that. We can start doing our whip stitch to secure these two ends together. So we've got several options here to continue to prep this graft. We have some new 1.3mm SutureTape loops that are either blue white or black white. We also have this 0.9mm SutureTape loop. And then we also have these 0.9mm suture tapes that are single stranded are loaded with a needle on either side. So a double needle single stranded 0.9mm SutureTape. Now I'm going to want to use a different type of suture for different portions of the graft prep. So when it comes to closing the loop and the free ends, I'm going to want to use a slightly stronger 1.3mm SutureTape loop. That's going to be good because it'll be a little bit bigger, a little bit stronger, and I can use that later on at the end of the case for backup fixation in a swivel SwiveLock on the tibia. When I cerclage the graft, I'm going to prefer the slightly smaller, single stranded, double needled 0.9mm suture tapes. All right. So we are going to use the black white 1.3mm SutureTape loop to whip stitch these ends together. So this will be standard. We'll do about three passes through here. Really make this tight. So I'll pinch the graft and I'll pull straight down so it doesn't separate the graft apart when I do that. Take slightly different passes. I don't want to pass everything perfectly in line. So you can see how those are slightly off from each other so it doesn't accidentally split the graft apart. Pull straight down and we can see we've got that whip stitched together now. Now the next thing we're going to do is we are going to cut this loop, take the needle off and cut the loop. And now we can And bring this in. And we're going to take one limb of suture this way and one limb of the suture this way, and then bring them up around this post here. So we'll just wrap them several times around this to kind of cleat the sutures, hold them in place. We've got our graft sitting just how we want it now. And now we can take this single stranded, double needled 0.9mm SutureTape. And now we can cerclage. Before we do the cerclage, we want to make sure that we create some reference lines on the graft. And this is surgeon preference. But we're going to demonstrate here because this is a 70 millimeter graft. We're going to mark two centimeters from either end as the spot where we do our cerclage here and here. And this will be this central 30mm will roughly be the intra-articular length of the graph. You can set it up differently, but this is how we're going to prep it for here. As long as you have something consistent for reference lines that's what's most important. So what we're going to do now is we're going to do the cerclage And we're going to take advantage of this single stranded, double needled 0.9mm SutureTape. And this is the black white version. We're going to lay the suture over the graft. And then we're going to bring each end around and kind of roughly keep them over that purple mark. And then we're going to take each end with the needle. And we're going to pass it from outside the graft into the center of the graft. And we'll use our purple marker as our entry point. And then we're going to come from outside in here just like that. Now we can cut our needles. And now we can dress this up. And then we can just tie the ends together. And that will give us a nice buried knot right here in the middle. Another popular way to do this is with another 0.9 SutureTape with just one needle. If you've got the two needles, you can cut one needle off, or you can have just a single needle suture open, and we'll demonstrate how to cerclage on this end right here. We'll start this from inside out Cerclage and then go outside in. And it doesn't matter necessarily how much tissue you grab here, as long as you just start on the inside. But we'll grab two limbs of graft material here. So we'll bring this all the way out and we'll leave just enough to tie. And now we can take this and we will pass it around the graft a couple times. And now we will come from outside in. Cut the needle off. Dress up the sutures so that they're all laying in the right spot. Okay. Once we've got the sutures dressed up again, we can hold them tight like that. And then? Then we'll just tie the knot. And then the ultimate. We're going to do two more cerclage here and here. So now we've got our graft completely sutured. You can see the four cerclage stitches along the length of the graft. And as you can see, this is very low profile. It doesn't add any bulk to the graft. And you can also see that it doesn't mummify the graft because we have a lot of collagen all along here that will be able to heal inside the tunnels. The last thing I want to show before we do our final sizing is here is our 1.3mm SutureTape that was placed earlier at the end of the case. This can be incorporated into a SwiveLock on the tibia for backup fixation. So now we have our graph completely prepped with our four cerclage stitches complete. Now we're going to do the final sizing and the final measurements. We'll double check our length and we are still right at 70. As you can see right there. Now let's see how it sizes. We were ten before and we can just do this right here. And so we'll pass this through. You can see it's kind of a tight ten right there as I come through. What we're going to do now is we're going to compress the graft with these compression tubes. And I think we can get this down to a nine. So we're going to take one end of the graft off of the prep station. We're going to grasp the sutures, pull it through the compression tube and then we'll pull this right on. You can see that easily gets into a nine. And now what we're going to do is we're going to leave this graft in this nine millimeter compression tube while we drill our tunnels. And then we'll only take it out once we're ready to actually pass the graft into the knee.

Patrick A. Smith, MD (Naples, FL), demonstrates the GraftLink® technique using a TightRope® II RT implant with FiberTape® suture for InternalBrace™ technique.
The InternalBrace surgical technique is intended only to augment the primary repair/reconstruction by expanding the area of tissue approximation during the healing period and is not intended as a replacement for the native ligament. The InternalBrace technique is for use during soft tissue-to-bone fixation procedures and is not cleared for bone-to-bone fixation.

GraftLink® ACL Reconstruction Using TightRope® II Implant for the  InternalBrace™ Technique

So I'd like to first show the new packaging for the TightRope two. Very convenient. Much smaller than before. And we've got both our T version with the button attached and the ABS attachable button system. And conveniently, the sutures are all packaged together with a quick flip. Everything comes undone. The features of TightRope two. Here we have both an RT version with a button attached and the ABS attachable button system without the button attached. First thing I want to point out is that it's taped now instead of suture, which has several advantages. One is it's softer and more protective for where the loop of your graft is here for fixation. And plus the tapes are much easier on your fingers. So you don't necessarily have to use the tension handles to get your good tension. In terms of the TightRope two, this particular version comes with the FiberTape already attached for the internal brace. The other big advantage of TightRope two is the improved stability of the construct. There's a fifth point of fixation, and I'm going to show you that here. I'm going to back up the tape a bit. You can see that there's an extra loop where the TightRope passes underneath the loop here. And that lock of that TightRope tape right there really improves the overall strength of the construct quite a bit. Two new features. Graftpro that are very helpful make things more convenient for us. And here for the button holder, as opposed to the past where you had to hold this. Now there's a little locking mechanism. Then similarly on the tibial side with the buttonhole here, same thing. You have a locking mechanism, so you free up. If you use a no button abs you just ring around the cleat. If you want a button on the tibial side, you can load it the same way and bring it back up to unlock it. So we're going to demonstrate GraftLink prep for you with a quadruple semitendinosus. Here we're showing the E-ZPass now of our TightRope RT button on the side. You can see with our new system, we just locked it, so and now we unlock it and hold the button in place. So this is the TightRope RT. It has the tape again. As I mentioned, we already have the FiberTape loaded as our internal brace. This is our passing suture. So this is the femoral side. So here on the tibial side we're going to use the ABS attachable button loop system for preparation of graft. You can see the loops pretty long. So it's very easy to just pull the shortening strands here. And you can decrease the loops like this. Make it a little more convenient a little smaller. And so now we're going to anchor it on the cleat to get our fixation, to be able to pass the graft and create our construct. So we just pull that it locks in. So here's our hamstring tendon. Generally my minimal length is 270 with all-inside technique which I'm going to demonstrate today. Typically your total graft length ends up around 65mm or so. So you don't have to have that long a hamstring. But what happens is frequently the harvest is 300 310, but allows you to freshen the edges and save the best tendon for that 270 distance. We have to start with quadrupling our tendon, so we pass through the tibial side first, and then we come on the femoral side, top down on the femoral side. Then we're going to do is one end of the graft is going to pass back through on the tibial side to meet the other end of the graft. So there you can see now I've got my two ends together. And I'm going to demonstrate a continuous loop technique today. So here's our quadruple graft. So I take A20 suture to suture these two limbs of the graft together pass underneath here to the other side and suture this side together in the same way. So that's three passes now. Then I just tie these suture. So I've linked it for a continuous loop. We like to bring our sutured end in the middle of the graft toward the tibial side. So we'll put a little tension. So you can see I'm just bringing that suture part to the inside. So now you can see it's quadrupled. I've buried the suture on the inside. The next thing we're going to do is I'm going to pass my internal brace between the two outer limbs of the graft. And essentially it buries the internal brace on the final construct. That's what I do, is I pass one end of the tape through this limb, and then the other end of the tape through the other outer limb. In this fashion, there's my IB construct. Now we're going to suture or link the four limbs of the graft together. And we do a wrap around cerclage type suture. The key feature with the internal brace, the way this is done is it's totally independent. So a helpful technique for making the graft is to pass a pickup between the middle. And that allows you access to better pass your needle. With our number two FiberWire suture the outer two limbs first of the graft toward the tibial side, avoiding the loops. And then I'll go through all four with my next pass with the needle. So now we pass that through. And then we'll cerclage it. I like to wrap it around three times and then we'll tension it. So once that's tightened now then I just tie it. We just cut the short strand above the knot. And then we can additionally bury the knot by passing through the graft here, making sure to avoid my tape. If you pull this you can pull the knot down. So that buries that knot. We can still move our tapes. The other thing is we have very little tension on the graft at this point. I then go ahead and increase my tension to about 75 Newtons. So here's our final construct quadruple Bio-Tenodesis GraftLink with the FiberTape InternalBrace passed independently through the femoral button. It's going to measure just about 69mm. So here we're sizing the graft and that's ten millimeters. So I do utilize the compression tubes on all of my soft tissue grafts, whether it be a GraftLink semitendinosus or a quad graft. Because I can usually compress a half to a millimeter in size. I measure ten millimeters on the graft with my preliminary measurement. This is a 9.5 compression tube. Got the little locking handle. Makes it easier to hold. So what you do is you pass your loop grasper through the smaller end of the tube. We'll take the graft off the GraftPro, and then we'll just simply grab our sutures with our loop, pull them through the tube, and then bring the graft in. So that's fairly snug. 9.5 I'm pulling pretty hard here, but you get the water out of the graft. Now you can see I'm totally seated in the nine five two and that's pretty tight. So for this case we'll drill A95 femoral socket nine five tibial socket. And sometimes you can go down maybe one more half size. But I think this half millimeter for this graft is what we need. This is a left knee. We're going to do a GraftLink ACL reconstruction with internal brace. I've cut out the ACL. We use the six nine guide on the femoral side. We come through the lateral portal because you can view from the medial portal. And one big advantage of the six nine guide is you can easily see it 90 degrees of flexion. You don't have to hyper flex the knee. So I'm going to position the six nine guide. The outer diameter is nine inner six. Our graph is nine five. So we've got a good idea of where this graph is going to sit. This is single bundle construct for me. And I'm a little bit more toward the Am bundle isometric. So I'm going to position the guide right where I want it. Toward the back here usually I leave about 1.5 to 2mm from that posterolateral position of the condyle. So what we're going to do now is lock it in place. Oops. So we double check our position, make a little stab blade through the IT band. Sorry. So we've got our six nine guide in place here. Good position on the side of the joint side. We've brought our guide sleeve down through the IT band down to bone. So now we're going to drill our FlipCutter three. Should come out right in the center of the six nine guide. So there we are. Disassemble our guide. There's our pin. So now we're just going to open our FlipCutter 3 to 9 five matching our graph diameter. Okay. So there's our femoral socket drilled to a depth of 27. Grab our FiberStick passing suture and dock that on the femoral side. So we've got good position They're on our side. We have our aiming device here through our Am portal. Got a little stump of the native ACL right there. Here's the anterior horn. Lateral meniscus. So we're going to position right like that right out in the stump here. Make a little incision. Okay. So now we're going to drill our FlipCutter three. Unlock our guide. Tap in our tibial guide sleeve seven millimeters. Open up our FlipCutter goes in as a 3.5 diameter pin. Open up to 9.5 to match the graft. There's our TigerStick now on the tibial side in our tibial socket. We have our passport cannula in place. So that's a good position on our tibia. Here's the anterior horn lateral meniscus. So that's a good spot. Here's our femoral socket. Good position. Retrieve my femoral shuttle suture. It's important. On the tibial side, we pass Ask the no button loop with a little cinch suture. That suture right there is going to pull the loop down that protects the shortening strands of the TightRope two with the tapes there. So this is just a shuttle suture that will go with the internal brace on the tibial side. We've pulled our femoral shuttle suture out the passport. So we have our passing suture which is blue for the TightRope two and the two shortening tapes. So we pull that across. So now here's our graph that's come out of the compression 95 tube. We're going to mark our graph two ended up at 68. We just measured it at 68 is where we plan on having 23mm of graft in the femoral side. There will mark right there at 23. And the intra-articular distance is 20. It's never more than usually 22. This is a small knee. So mark 20 from that point. So that leaves us 25 in the tibia. Then we're going to mark where we expect our button to flip. We measure the interosseous distance at 37. So if we take our button and hold it lengthwise. Mark from that point 37. So that's what we expect to see the the button flip on the femoral side. So that's the interosseous distance of the femur at 37mm measured from the back end of the button. Because the button goes through the whole lengthwise. So we want to know that distance where the back end clears the femur. And that's when we should feel and see the slippage. So now we're going to pass our graft through the passport cannula. In the medial portal we have our femoral shuttle suture. Here comes our button. Now I'm going to come in with the scope behind it. Watch our button. Come into the femoral socket and flip it on that femoral hole. You can see the hole there. There goes the button. There's our mark. So we have a couple more millimeters to go. And that's when we should see it flip. So one advantage of the independent internal braces. Remember the internal braces through the femoral button? We just flipped it on the lateral cortex. So we pull hard on the on the internal brace you can see the femur moving. So what this does it really seats that button. And on post-operative x rays the button sits flush on the cortex because you're reducing the button right down by pulling on the internal brace. So another advantage of the internal brace. So we're hoisting the graft up into the femur to our mark which is 23. So we're going to pass the graft into the tibia. Next take our loop suture here. So here we're passing the two ends of the internal brace and the loop suture which has the shortening strands that will pull the graft into the tibia. So bring the two shortening strands out. And we'll take off that loop. So now we'll just pull the graft into the tibia. So there's our graft. So now let's show you the fixation. Okay, so the first order of business is we put the 14 millimeter ABS button on the no button. So we're putting the ABS button here which is 14mm. Now I like this button because it has two holes. And through those two holes I pass the internal brace. So one IB and the second. So now what we're going to do is I'm going to fix the internal brace first. But to do that I like to bring the shorting strands bring the table button down to bone here. I do this in full extension. So I'm going to do here is I'm not tightening the tibia. I'm just going to bring the button down to the tibia here. I keep my length about the same. So here's our abs button. Here's our two tapes for the TightRope two to secure the graft in the tibia. But I'm going to do that second. Here's where I pass the two ends. The internal brace through the two button holes in that ABS button. Again this is 14mm. It's very important. When we fixate the internal brace I fix the internal brace first. I do that in full extension or full hyper extension, but I do. So I want to make absolutely sure that the line of the InternalBrace fixation doesn't compromise my ability to tension the tapes. So you wouldn't want to put the button over this way, because that could constrict the tape tightening for the tibial fixation. So we want to be in line so that these two tapes are free on the button so I can tension them. Second. So I see my position there. So I'll drill a hole in the tibia about a centimeter half distal to the button. This bone is hard. This helps. This is a new 5.2mm tap bit oversize to help with that 4.75 SwiveLock, which is what I fixed the internal brace, but you have to tap this bone. So I've taken the tension out of the two tapes. We're going into full extension. Here's my 4.75 SwiveLock anchor. Find my hole. And this is self tensioning. You just let go of the tapes and secure the SwiveLock. Hold the paddle here. That good squeak. So that's the internal brace fixed first independent of the graft. So our SwiveLock is down. We'll tap this off. Take out our safety suture. So here's our fixation. I'm going to cut my tapes for the IB. But again you can see that I've left room to be able to tension the tibial into the graft. So there's no constriction by the tapes. That's really important. So again in full extension I'm going to tension our graft on the tibial side. And then we'll cycle the knee. I like to cycle the knee 20 times at least. So after I cycle the knee I like to retension the graft. So we use these tensioning handles which give you more force to apply those first on the femoral side. Basically just put a wrap around the middle of the slot in the handle. Again I go into full extension. I don't want to over constrain the knee. And this graft will be tight. And I don't want to put it in flexion and risk the patient losing full extension. So now I'm on the tibial side again. The knee is at full extension. So now I use the handles here to tighten the tibia one more time. So again re tensioning. The nice thing about the TightRope two with that special, that special fifth locking mechanism, you don't have to tie the tapes here to the button. Now we'll look at the final construct. But what I want you to notice here is one of the limbs of the tape. And see the tape is loose in flexion. We put it in full extension when we fixate it. It's a really important point. This is a seat belt. It's going to function at high loads. When it's when stress comes off the graph the tape kicks in. That's a really important point. You can see here full extension. We don't do a notch Plasty. You can see now the tape tightens up in extension there. It's tighter flexion. And then now you can see the tape will loosen a little bit as we flex the knee. There's the looseness of the tape. As we bring it into extension. It starts to tighten and pulls my hemostat my probe off. So there it is. Tighten extension now. So that's a nice GraftLink quadruple semitendinosus.

GraftLink®  ACL Reconstruction  With ACL TightRope®  II Implant  for InternalBrace™ Technique

This animation demonstrates the ACL GraftLink® technique using FiberTape® suture for the InternalBrace™ technique.&nbsp;
The InternalBrace surgical technique is intended only to augment the primary repair/reconstruction by expanding the area of tissue approximation during the healing period and is not intended as a replacement for the native ligament. The InternalBrace technique is for use during soft tissue-to-bone fixation procedures and is not cleared for bone-to-bone fixation.&nbsp;

GraftLink® Technique Using FiberTape® Suture for the InternalBrace™ Technique 

Graftlink ACL reconstruction using a TightRope two implant and the internal brace technique. The GraftLink construct includes a TightRope two implant that is preloaded with FiberTape suture for the internal brace technique, and features new flat tape loops and tensioning strands for improved strength and handling, and a broader suture graft interface. The TightRope two implant uses an improved button design, incorporating a proprietary knotless fifth locking point that increases strength and resists cyclic displacement. Place the ACL femoral guide over the ACL femoral footprint. Arthroscopically. Adjust the angle of the guide to the desired position and tunnel trajectory, and then lock into place. Push the ratcheting drill sleeve down to bone. Advance a FlipCutter three drill pin through the ACL femoral footprint. Tap the tapered portion of the stepped drill sleeve into the femur seven millimeter or until resistance is felt when reaching the femoral cortex. Using the wheel, deploy the FlipCutter three. Drill to the appropriate size and retrograde. Drill back to the sleeve to create a socket. Remove the FlipCutter three. Drill and pass a blue and white FiberSnare suture through the drill sleeve. Retrieve it from the lateral portal and dock it for later graft passage. Remove the stepped drill sleeve. Place the ACL tibial guide over the ACL tibial footprint arthroscopically. Adjust the angle of the guide to the desired tunnel position and tunnel trajectory, and then lock into place. Push the ratcheting drill sleeve down to bone. Advance the FlipCutter three. Drill through the ACL tibial footprint. Tap the tapered portion of the stepped drill sleeve into the tibia seven millimeters or until resistance is felt when reaching the tibial cortex. Using the wheel, deploy the FlipCutter three. Drill to the appropriate size and retrograde. Drill back to the sleeve to create a socket. Remove the FlipCutter three. Drill and pass a black and white FiberSnare suture through the drill sleeve. Retrieve both of the FiberSnare sutures from the medial portal, and remove the stepped drill sleeve with the blue and white FiberSnare suture. Pass the femoral side of the GraftLink. Construct into the femoral socket until the button flips on the femoral cortex. Use the tensioning sutures of the TightRope two implant to advance the GraftLink. Construct into the femoral socket with the black and white FiberSnare suture. Pass the FiberTape suture for the internal brace technique and the abs. Tightrope two. Implant into the tibia with the knee in extension, use an 11mm, three hole concave button for tibial fixation of the GraftLink construct with the FiberTape sutures for the internal brace technique loaded through the larger oblong hole before tensioning the GraftLink construct. Anchor the FiberTape sutures for the internal brace technique using an ACL backup fixation kit. Using the spade tip drill followed by the 5.2mm tap, place the FiberTape suture for the internal brace technique into the eyelet and screw the 4.75mm SwiveLock anchor into the drilled hole. Take the knee through range of motion and then perform final tensioning on the GraftLink construct.

GraftLink® Technique Scientific Update

Hamstring Autograft ACL Reconstruction

For primary and revision ligament repairs and reconstruction procedures, a variety of tendon allografts—including a wide portfolio of presutured tendons—are available. &nbsp;Allograft tendons provide many benefits compared to autograft tendons in reconstructive procedures, including less donor-site morbidity,1,2 fewer incisions, shorter operative time,1,2 larger and predictable graft sizes,2 and decreased postoperative pain and stiffness.2&nbsp;
 
Choose from sterile or aseptically processed tendons. Sterile tendons from our tissue bank alliance partners are rendered sterile without biomechanical or biochemical changes to the tissue.&nbsp;
 
Presutured constructs are an off-the-shelf solution requiring minimal preparation time while providing surgeons with a high-quality, consistent, sterile, and strong allograft tendon.&nbsp;
References
1. Edgar CM Zimmer S, Kakar S, Jones H, Schepsis AA. Prospective comparison of auto and allograft hamstring tendon constructs for ACL reconstruction. Clin Orthop Relat Res. 2008;466(9):2238-2246. doi:10.1007/s11999-008-0305-5
2. Greenberg DD, Robertson M, Vallurupalli S, White RA, Allen WC. Allograft compared with autograft infection rates in primary anterior cruciate ligament reconstruction. J Bone Joint Surg Am. 2010;92(14):2402-2408. doi:10.2106/JBJS.I.00456
Disclaimer: Allograft product offerings depend on country approval and product availability.

Orthobiologics

Arthrex offers a variety of tendon allografts, including a wide portfolio of presutured tendons, for primary and revision ligament reconstruction procedures. This animation highlights the comprehensive presutured allograft tendon portfolio and potential applications.&nbsp;

Presutured Construct Tendons

Allograft Tendons: A Comprehensive Portfolio

Allograft GraftLink® Construct

Michael G. Baraga, MD (Miami, FL), performs an ACL reconstruction using a QuadLink™ presutured allograft, a TightRope® II BTB implant preloaded with FiberTape® suture to perform the InternalBrace™ technique, and a TightRope II open ABS implant.
The InternalBrace surgical technique is intended only to support the primary repair/reconstruction and is not intended as a replacement. The InternalBrace surgical technique is intended only for soft tissue-to-bone fixation and is not cleared for bone-to-bone fixation.

ACL Reconstruction Using QuadLink™ Presutured Allograft and TightRope® II Implants

So the QuadLink graph is a pre sutured quadriceps tendon construct. It comes prepared with FiberLoop with FiberTag for secure fixation and addition of our TightRope constructs, very similar to the GraftLink with the new TightRope two implants. The first thing you'll notice is an improved packaging, which allows an easier deployment and building of the construct. The first change you'll notice is the addition of SutureTape, which provides less stress on the graft, wider area of contact, as well as an improved strength of the construct. It also has an added locking mechanism which helps reduce cyclic displacement. Another key feature that you'll notice is also the addition of the FiberTape included already in the construct, which really helps speed up the building and putting together of the entire graft construct as the tape is already included in the button. And finally, a nitinol wire to help assist with building the construct and shuttling the sutures internally. So our QuadLink allografts come in sizes ranging from nine millimeters in diameter to 11mm in diameter, and lengths ranging from 68 to 73mm. Perfect for the all-inside technique. What you'll notice once you take it out of the packaging is you have one side with one set of sutures, and the other side with two sets of sutures. The second, thinner set of sutures serves as a tibial backup fixation. If you're interested in using this into a SwiveLock anchor, you can keep these in the construct. However, if not, you can always remove these prior to graft preparation. Okay, so for this construct we are going to use the BTB TightRope two with internal brace for the femoral side and the TightRope two ABS for the tibial side. All right. So we'll start our graft preparation with the tibial side with the TightRope two abs. We'll start by cutting off the needle since it will not be necessary for this graft construct. Once the needle is off and the loop of tape is unraveled, we can take this to the graft. We'll take the loop. Once we pass the loop through the loop, we'll fold this down, pull through, get it engaged, and then pull firmly to pass it through the other side. Once the loop of tape is through the graft, you'll want to take the free limb of the SutureTape and pass that through that loop and then into the nitinol wire. Once it's in the nitinol wire, you want to secure the card and pull firmly proximally to build the construct. Now you'll want to remove the sutures from the card. Once the construct is built, we can then pull on the free limbs of the tape to even out the construct and set it at the appropriate length. So for our femoral side, we'll use our BTB TightRope two with internal brace. We'll start by cutting off the suture From the needle. So we don't need the needle for this construct. And we'll then un cinch also the loop suture to shuttle through the graft. All right. So through the loop of the shuttling suture we'll pass the loop of the suture tape from the TightRope and pass this through to the other side. We'll take the free end of the SutureTape, which is the number two, and pass it through the loop that was passed through the graft. We'll then bring the free end back in through to the card to the nitinol wire loop, where we will set this. Pulling proximally and holding the card firmly at the top can easily pull this through and finish building the construct. All sutures are then removed from the card, including the internal brace which is in the back. And now we can separate the sutures and pull on the free ends in order to set the appropriate length of the construct. Okay, so here we have our final construct of our QuadLink allograft. And what you'll notice real quickly if we look at the graph, this graph is under 80 newtons of tension. Right now. There is no gapping in the TightRope in either end from the construct pulling away. So this is number one. It's a secure construct. So second, what we've done also is we've taken the tape sutures from the internal brace and passed these through the whipstitch sutures on the graph. Now these are loosely passed through. So these can really slide easily. They won't hold the graph back in terms of graph passes, but it does keep the tapes tight to the graft to help with deployment. And on the tibial side, we've added a safety stitch to pull when we're pulling the graph through into the tibial socket. And we've also marked the free ends of the TightRope mechanism to easily identify them as the free limbs once they're pulled through. Now that we have the final construct, we can go over to our Arnie for demonstration of the surgical reconstruction technique. So we are in this left knee and we've already cleaned out the the ACL. And we can see visualizing from a lateral portal. We can visualize the wall. We can see the extent of the native femoral footprint. We can also see on the tibial side the extent of our tibial footprint with a great view across after resecting the fat pad. Now for femoral socket preparation. I do like to visualize more from the medial side, and I do use a three portal technique which does allow a low anteromedial portal, which I've already established as close to the femoral condyle and as close to the meniscus as possible, but safely. And now we can see where we are, we can see the footprint entirely, and we can bring in the offset guide. Now I trained using an offset guide. So this is what I've always used. But I basically use it as sort of a guide to float the pin to the spot that's going to be in the middle of it. Now we can see the knee in this position, but once we hyper flex to really get that angle, we angle, we flex the tibia. Here you can see how that footprint, if you keep going, kind of rotates a little bit more anterior. So if you just place the guide posterior and forget about it, you might be a little too posterior. Whereas in this scenario it might be a little more favorable to float the pin more so into the center of our footprint where you can see this a little bit easier right here. So this is where we would be if we were off the back wall. You can see the center of the footprint is slightly anterior. So we'll place the pin right in the center of that and we'll get ready to fire that across. With the pin held in the center of the footprint. We can fire it in from here. Or we can get the guide out of the way and really inspect where our positioning is in the center of the footprint. And we can also visualize also from the lateral portal. Where we can see where we are in terms of the posterior aspect and the anterior aspect. So we'll get an LP reamer size to our graft. For an all inside technique, I typically go between 20 and 25mm depending on the size of the graft right there. And again, you can take this moment to really see the extent of your socket and how it fits inside the footprint compared to the reamer. All right. So let's take that to a depth of about 25. Perfect. All right let's get the reamer out. All right. All right. Cool. We'll pull our shuttling suture through keeping the loop on our end. Yep. And then we can just cinch this on the back over here. Perfect. All right, now we'll go to the tibia. Mark our spot that I've already marked with the RF and set our target line. Mark the skin. Make our incision. We'll take the guide off and visualize. At this point, we can see it from the medial side coming in more medial than lateral. We can see it right behind our anterior most fibers right in the center of where the majority of the ligament lies. We'll mallet this into place. All right. We'll take this a little bit higher. Make sure we have clearance. And we'll go ahead and take this back to a depth of 25mm. We've pulled our femoral suture shuttling suture into the joint. We're ready for our passport cannula. And now we can retrieve the suture out of our passport and get ready to pass the femoral side of our graft. We're ready to pass our femoral side, so I'll hand over the sutures. Pass them through. We'll pull on the femoral side. Yep. Pull those through. Perfect. All the way through. All right. And now we'll get ready to pull the graft into the socket. I personally like to switch over to then to my more central portal. And that gives me a view straight up the socket so I can see when the button is deploying. So we'll go ahead and pull these as you usually would with any other TightRope mechanism. All right. And as we start getting closer all right you can see the button coming up to the aperture. So at this point we'll just pull on the blue sutures. Got that to pop through. And that's it. And then you can see it directly flip. And then we can pull back inside the abs and feel that flip back on the cortex and you can hear almost hear it. Back on the cortex. No need for fluoro. No need for any other verification there. So once that is set, you can pull on your tapes, keep that button on that cortex. And then we can start synching the TightRope mechanism on the femur. You can keep tension individually on those tapes. This will slide right over them. Yep. There we go. Perfect. We'll graft going into the socket. Good. You can always with good press fit. Sometimes you have to assist a little bit at the edge with the probe. All right. There we go. Perfect. All right. Excellent. We'll stop right there and we'll finish bottoming that out later. Now we'll hold all the sutures here. Let's pull these proximally and we hold tension on these up. I'll slide on the bottom of our passport into the bottom over here, where we'll push our TigerStick and we'll grab that suture. We pull that back a little bit. Perfect. Got it. Excellent. All right, so our sutures are here. We'll take now the tape, sutures and our blue cinch suture. So for this, we've identified what our tensioning sutures are. We'll keep those out of this. We'll take our safety stitch and our tapes pass them through. Once everyone is in, we'll pull on the tiger. Shuttle that through. Everyone comes through. We can now pull everything down. We've now identified already which one our tensioning sutures are. Which are the purple ones that we marked. So we can easily bring these down from inside the joint. We can pull our passport back, which can sometimes get a little bit in the way we don't need it anymore at this at this moment. And we'll go ahead, dunk our graft, pull tension on our tapes, and our graft is seated into the tibia. And we can now see our construct from the tibia to the femur. You can visualize it also from the anteromedial aspect. Coming down into the footprint you can visualize range of motion as we come into extension. And we'll proceed then to fix this on the tibia. So we'll set up for tibial fixation. Now the first thing we do is we remove our safety stitch from the tibia. Simply pull that little cinch off okay. We'll take our 11 millimeter. Button. We'll load. Our tightropes On either side, and then we will load our internal brace on the sides of these as well. We'll hold our tapes out. We'll provisionally bring this down to the anterior aspect of the tibia. Now this is not setting any tension yet. We're just basically sliding this down to the cortex. We'll place the knee in the appropriate position. Near full extension is what I prefer. And then now we can fix our internal brace into a swivel lock anchor. And then we'll recycle and tension our graft. We'll take our sutures from our internal brace and load them into a 4.75mm swivel lock anchor. Proceed to drill. Tap. And we'll hold the knee at full extension. Release our anchor mallet. Excellent. We'll go ahead. See that? We're down a few more turns. Perfect. Let's take our inner sutures out. Excellent. All right. Now, the knee will already be stable from the internal brace, but now we can cycle the knee, take it through full range of motion 25 times. Really? Test your lochmann. Test your anterior drawer pivot if you want. Really stress that so that we can now then come back and Retention. Okay, so we'll hold the knee posterior drawer. Okay. We'll begin with the tibia. And you can really feel the difference of the tape certainly on the fingers as you're re tensioning this. You can also appreciate how it will have the same effect on the graft. The broader suture larger surface area. So retention on both sides. Again you can reexamine feel. That'll be it. Remove the flipping suture. Cut these down and we're good to go. So yeah. So there's our construct with the QuadLink allograft using the TightRope two devices, both our BTB TightRope two with internal brace and TightRope two ABS on the tibia.

Allograft Tendons – Sterilization

Allograft ACL Reconstruction

The BioACL technique harnesses the power of next-generation biologics to provide the ultimate anatomic, minimally invasive, reproducible approach for taking patient outcomes to the next level.
By prefilling ACL bone tunnels with a powerful composite of concentrated platelet-rich plasma (cPRP) from bone marrow aspirate (BMA) or whole blood processed with the Angel® system, the patient’s own bone collected with the GraftNet™ device, and AlloSync® Pure demineralized bone matrix, the BioACL technique provides all the necessary healing components for an ACL reconstruction procedure.
In conjunction with the QuadLink™ with InternalBrace™ technique, the BioACL technique has been shown to result in earlier range of motion, improved limb symmetry, less bone-tunnel widening, and improved patient-reported outcomes as compared to nonaugmented ACL procedures.1&nbsp;
 
 
Reference
1. Lavender CD, Schaver AL, Taylor S, et al. Anterior cruciate ligament reconstruction augmentation with bone marrow aspirate concentrate, demineralized bone matrix, and suture tape shows no difference in outcomes—but faster functional recovery—versus non-augmented anterior cruciate ligament reconstruction. Arthroscopy. Published online July 22, 2024.&nbsp;<a href="https://doi.org/10.1016/j.arthro.2024.06.042">https://doi.org/10.1016/j.arthro.2024.06.042</a>
 
The&nbsp;InternalBrace surgical technique is intended only to augment the primary repair/reconstruction by expanding the area of tissue approximation during the healing period and is not intended as a replacement for the native ligament. The&nbsp;InternalBrace technique is for use during soft tissue-to-bone fixation procedures and is not cleared for bone-to-bone fixation.

BioACL™ Surgical Technique 

The BioACL™ technique augments ACL reconstruction with an unmatched combination of the patient’s own biology, the highest-quality biologics, and the proven technology of the QuadLink™ technique with the InternalBrace™ procedure to maximize healing potential.&nbsp;
 
The InternalBrace surgical technique is intended only to augment the primary repair/reconstruction by expanding the area of tissue approximation during the healing period and is not intended as a replacement for the native ligament. The InternalBrace technique is for use during soft tissue-to-bone fixation procedures and is not cleared for bone-to-bone fixation.

BioACL™ Technique Animation

Chad D. Lavender, MD (Scott Depot, WV), demonstrates an all-inside QuadLink™ ACL reconstruction with an InternalBrace™ augmentation after back filling the femoral and tibial tunnels with AlloSync™ Pure and autograft bone collected with the GraftNet™ device.

Augmentation of a Quad Tendon All-Inside ACL Reconstruction With Bone Marrow Concentrate Mixed With AlloSync™ Pure Demineralized Bone Matrix and Autograft Bone Collected With the GraftNet™ Device

Hello, this is Doctor Chad Lavender with Marshall University orthopedic sports medicine. And I'm going to present a case of augmentation of a quad tendon all-inside ACL reconstruction with bone marrow concentrate mixed with AlloSyncPure and autograft bone collected with the Arthrex GraftNet. This case is an 18 year old football player. He had a non-contact right knee injury, noticed a pop and an effusion, pain with weight bearing and he had a contralateral BTB ACL reconstruction I had performed one year prior to this. His exam showed 0 to 130 degrees. Range of motion. Positive. Lachman. Positive. Pivot shift. Moderate. Hemarthrosis. Here you can see his MRI showing the ACL rupture. So in this patient we elected to do an all-inside ACL reconstruction with quad tendon autograft augmented with bone marrow concentrate mixed with AlloSyncPure and autograft bone collected with the GraftNet device. Here you can see our technique video detailing this surgical technique. First, before the tourniquet is inflated, we aspirate 60 ccs of bone marrow aspiration from the From the proximal lateral tibia. Here's the quad tendon graft prepared on the back table. First, we will drill the femur in retrograde fashion with the FlipCutter. As you can see here, the GraftNet has been attached to the shaver which has been placed into the lateral portal. And as you can see, we are harvesting the reaming from the femoral tunnel using the GraftNet device. Here's the autograft bone within the GraftNet. Next, we will turn our attention to the tibial tunnel. A GraftNet attached to a shaver with suction has been placed through the medial portal. Here you can see the tibial tunnel reaming being taken up through the shaver and into the GraftNet there is the GraftNet with the bone graft within the GraftNet on the back table. In this case, we obtained four CCS of autograft bone using the GraftNet that was then mixed with five CCS of AlloSyncPure, which was mixed with five CCS of bone marrow concentrate. Next, the TightRope is then flipped on the femur. And here you can see delivery of the composite graft into the femur from the medial portal. We recommend fully filling the tunnel with the composite graft. Next, we will come from the lateral portal and deliver the composite graft into the tibia. We like to see slight fluid leak from the cannula, to allow us to know that we have properly impacted our composite graft into the tunnels. There is a view of the tibial tunnel completely grafted with our composite graft. Next, the femoral side of the ACL graft is delivered into the femur and the tibia is placed down into the tibial tunnel. We sequentially tighten the femur and then the tibia. And here you can see the final construct with an internal brace applied. Here are the patient's post-operative x rays. As you can see he's one year out on the opposite knee from a ACL reconstruction. He has obvious tibia and femoral tunnel widening. He's six weeks out on the fertilized ACL reconstruction. And you can see a significant improvement in his bone.

BioACL™ Technique

It is estimated that between 1.8% and 10.4% of patients who undergo an ACL reconstruction will require a revision.1 Restoring a previously malpositioned ACL tunnel or widened tunnels can be challenging, sometimes requiring a two-stage approach.2 The Cannulated Bone Dowel Kit offers surgeons a simplified solution to effectively address these issues. Allograft bone dowels act as a biologic scaffold to provide an immediate structural architecture and promote osseous integration. The bone dowels can be soaked in platelet-rich plasma (PRP) or bone marrow concentrate to provide autologous cells and growth factors that facilitate graft incorporation.
Additionally, press-fit nature and structural integrity of the bone dowels provides surgeons the option to take a single-stage approach in cases where no more than half of the failed tunnel is violated. Favorable outcomes have been reported for patients undergoing single-stage ACL reconstruction using allograft bone dowels.3 &nbsp;
Along with allograft bone dowels, the FlipCutter® III drill is particularly advantageous in setting a revision ACL reconstruction. The all-in-one adjustable guide pin and reamer allows surgeons to precisely debride remnant tissue and maximize residual bone stock during tunnel preparation.
References&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
1. MARS Group, Ding DY, Zhang AL, et al. Subsequent surgery after revision anterior cruciate ligament reconstruction: rates and risk factors from a multicenter cohort. Am J Sports Med. 2017;45(9):2068-2076. doi:10.1177/0363546517707207
2. Richter DL, Werner BC, Miller MD. Surgical pearls in revision anterior cruciate ligament surgery. when must I stage? Clin Sports Med. 2017;36(1):173-187. doi:10.1016/j.csm.2016.08.008&nbsp;
3. Werner BC, Gilmore CJ, Hamann JC, et al. Revision anterior cruciate ligament reconstruction: results of a single-stage approach using allograft dowel bone grafting for femoral defects. J Am Acad Orthop Surg. 2016;24(8):581-587. doi:10.5435/JAAOS-D-15-00572
<ul>
 <li>Revising Two-Stage BioACL Technique
 <ul>
 <li><a href="https://www.arthrex.com/orthobiologics/bioacl-technique">Arthrex - BioACL™ Technique</a></li>
 </ul>
 </li>
 <li>Revising Two-Stage Quad Tendon Autograft
 <ul>
 <li><a href="https://www.arthrex.com/knee/quad-tendon-graft-acl-reconstruction">Arthrex - Quad Tendon Graft ACL Reconstruction</a></li>
 </ul>
 </li>
 <li>Revising Two-Stage BTB Autograft
 <ul>
 <li><a href="https://www.arthrex.com/knee/acl-btb-graft-fixation">Arthrex - BTB Autograft ACL Reconstruction</a></li>
 </ul>
 </li>
 <li>Revising Two-Stage HT Autograft
 <ul>
 <li><a href="https://www.arthrex.com/knee/hamstring-autograft-acl-reconstruction">Arthrex - Hamstring Autograft ACL Reconstruction</a></li>
 </ul>
 </li>
 <li>Revising Two-Stage Allograft
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 <li><a href="https://www.arthrex.com/knee/allograft-acl-reconstruction">Arthrex - Allograft ACL Reconstruction</a></li>
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 <li>Allograft Bone
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 <li><a href="https://www.arthrex.com/orthobiologics/allograft-bone?objectID=human.taxonomy_item.en.e41edfe6-c0f7-445f-91b9-930ee54d242b&amp;queryID=7c33852b43f7f746d4376f56bca1f901">Bone Grafting with Revision Bone Dowels 
Arthrex - Cannulated Revision Bone Dowels</a></li>
 </ul>
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</ul>

Mark D. Miller, MD, (Charlottesville, VA) provides a cadaveric demonstration of a single-staged ACL reconstruction using cannulated allograft bone dowels and FastThread™ interference screws.

Revision ACL With Cannulated Bone Dowels and FastThread™ BioComposite Interference Screws

What we're going to demonstrate today is a one stage revision ACL reconstruction. You can do an ACL reconstruction either 1 or 2 stages. It depends upon the size of the defect, that is the osteolysis of the tunnel and also the location of the previous tunnel. So we'll insert the arthroscope into the knee and we'll take a look at what we have. And so here we see a femoral tunnel that is somewhat more vertical than we would like. You can see how this is a very common error in ACL reconstruction is to have a vertical and often two anterior placed tibial tunnel. So I don't know about the anterior. Not too bad here, but it certainly is more vertical than I like. And it's not an anatomic ACL position on the tibial side. We also have a non anatomical position that's slightly violates the medial tibial plateau. I commonly see this as well. And so what we're going to going to do is to place our new tunnels in a location adjacent to, but perhaps even abutting the previous tunnels. In order to get by with that, we need to fill those tunnels with something to keep our new tunnel from migrating into the old tunnel. And what we're going to use for that is allograft dowels. They work really well to place into defects, and they will serially fill in and integrate into the old tunnel. We have soaked this in concentrated PRP from BMA, and this allows the dowels to perhaps integrate even better. So this femoral tunnel was placed in two vertical of a fashion. The femoral tunnel needs to be lower on the wall to be anatomic. In many cases this will be filled in with fibrous tissue and difficult to visualize. Therefore, we'll take some type of dilator as shown here. Insert it into the knee. And place it in the old tunnel to center. Center this in the previous tunnel, and then we can ShaverDrill this with a drill pin. And once we get it centered, we can take our dilator out and push it in the rest of the way. And that way, we'll look in this portal and confirm that we're in the center of the tunnel. So you want to be at the center of the tunnel, because as you drill, you want to make sure you don't drill eccentrically. You want to open up that previous tunnel symmetrically. So what we'll do is we'll drill this. Now, if it's a big tunnel, I'll really drill it, starting with smaller drill bits and then getting up to the size that I want. In this case we're going to start with a nine millimeter drill bit. And we'll drill that. We want to drill it to the size that we'll have a dowel available. We know from this that our dowel is 25mm. We've already sized it and therefore this will be a good location, a good drill for that. The other issue is after you do your drilling, you need to look up into the tunnel. And I call this tunnel and confirm that you have nothing but bone all the way around it. If you have soft tissue at this point, you'll need to drill further additional drilling until you have all bone on tunnel. Copy. So because we have that, we can use this special cannula to allow us to advance it without impinging upon other structures in the knee. And then we can advance this dowel through the cannula using this new device and a mallet. So here we see the dowel coming into place. So there's our previous tunnel. Remove our guide pin and look carefully at our dowel. And you can take a shaver or a bur and smooth it out if you like. So now we have essentially a primary ACL reconstruction to take care of. Our dowel has filled the previous defect. So what we'll do is we'll find a location for our accessory medial portal, usually about a centimeter medial to the previous incision a bit lower. And to test it out, see if we can get to where we want to through that portal. Looking over at this side to make sure we're not going to injure our medial femoral condyle. And it looks good. 11 blade. We're going to go with that for an accessory medial portal. Now independent femoral tunnel drilling can be done with an accessory medial portal. It can be done with a flexible drill. Or it can be done with an outside end technique. Three different ways to get there. So it doesn't matter how you get there as long as you get there. So in this case we're going to use the accessory media portal. So what I like to do is I like to locate where I'm going to place that. And you can use guides too. And I want to put it right about here. Now that's okay. If it's close to the old the old tunnel, as long as it doesn't violate more than half of the old tunnel, we're probably okay. So let's hyperflex now. And so we're going to flex that up, push this pin in. And then retrograde that pin back please. So we don't worry so much about where that pin is until we want to look at it at 90 degrees. The thing about hyperflexion it's very distorting to your view, so don't worry about it. Go back to 90 and look at it. So here we are back at 90. Here's our new pin. There's our old tunnel. And you can see that we have a step off of about 7 or 8mm which is going to be ideal. And so we like that pin placement. So the idea is to avoid damaging that medial from a condyle with a drill bit such as this. So the whole point is you want to get by that medial from a condyle without causing any damage. So we hyperflex and we drill this to 11mm. Now our graph is about 20. So that should be adequate. And we're going to check this out. Here's our new tunnel. Much slower than the previous tunnel. Here is our old graft. And again our dowel is still in place even though we violated part of it. As long as you don't violate more than 50% of that dowel, it's fine. So, new tunnel dowel still intact, and we're ready for to pass our graft. So now we're ready to pass our passing suture for the femoral side. Here, we've got this pre-prepared. Put this into the center of our hole. All right. So now we're prepared to pass our femoral side. We need to park it. We're going to park it so it doesn't get away of our tibial tunnel. We'll revisit that later. So now let's look at the tibial tunnel. Here we have a tunnel. As I indicated. That's a little medial and a little posterior. I prefer my tunnel in the anterior one third of the footprint. Now here you can see the lateral meniscus, even though it's badly degenerated. That's a one landmark for your tunnel. Also, you want to be just in front of the eminence. So what we're going to do now is backfill our tibial tunnel, and then we'll place our new tunnel, making sure we don't violate more than 50% of the dowel. We center our guide pin. So we put our pin in. We take our Kocher, grab hold of it. All right. So we place that right in the center and we can control where this goes. You see I can go more medial. Lateral I want to stay right in the center. We serially drill this until we have nothing but bone on NanoScopic. Now, the tibial tunnel will often be bigger than the femoral tunnel, so it's not unusual at all for the tibial tunnel to expand as much as 16 or 18mm, and therefore this new kit allows us to address that kind of tunnel. Osteolysis. And here's a nine. This is a cadaver specimen, and this tunnel looks pretty good. Even though we haven't really drilled again in revision ACL setting, you'll often need to drill several times in serially increasing your diameter of your tunnel. So it's not unusual to 12, 12, and then 14, then 16, and even often 18 before you have nothing but cancellous bone. When you look up the tunnel, this is what you want to see in this simulation. This is less diameter than we usually see in the tibia. So here we have our presoaked dowel again. And it's sometimes helpful to leave the water off while we place this so that we can preserve as much as that as possible. We put it over again. It's cannulated nicely. We put it into the the previous tunnel We take our new cannulated tamp and carefully tap it in. You can start to see it come up the tunnel on scope. Go ahead. Now slow down. So we want to have that end up just flush with the tibia. So you want to have that exactly flush again like we did in the femur. You can also blur this a bit because sometimes it'll be a little uneven obviously because this is not a perfect cylinder here. But in this case I'm pretty happy with that. So on the outside, but you can see right here it's really close to the cortex. So that's okay because your new tunnel is going to diverge from that. You can fill this with a substance such as AlloSync that will allow it to fill it up the rest of the the rest of the way. Okay. So now we're ready to drill our tibial tunnel in our new location. You want to avoid tunnel convergence. So whatever I can do to do that, including placing it more medial on the tibial side and also placing it more anterior. And also placing on the intra-articular portion anatomically where you want to be. Again, I like to place it in the anterior aspect of the previous graft. Good. So let's go ahead and ShaverDrill this. Now we like this location. We're going to use our 11 millimeter drill bit. Good. Great. Okay. So now we're going to clean up this tunnel and see what we got. But we've pretty much avoided the old tunnel. There's the dowel right there. See that? How about that? And we can avoid migration of our graft into what would have been an oval defect. Okay. We retrieve our passing suture. Here we have a bone patella, tendon bone graft that we've prepared to fit through 11 millimeter tunnels. The femoral end is bulleted Tted and marked so that we can see it intra-articular on the tibial side. We've placed perpendicular sutures. That way, if your interference screw happens to cut one of the sutures, it won't cut both of them. So we can pass our passing sutures in, and then we're able to pass our graft subsequently. What really helps here is to take a right angle forceps and to pull forward as we pull in this suture. So there's our graft. We're going to turn our water back on. Now here comes our graft passing into the femoral side. Good. So you can see the graft is right adjacent to the previous plug. There's the plug. There's the graft. So what. My interference screw is going to go between the two. Securing both of them simultaneously. Okay. Here comes the nitinol. Wire needs to be inserted in between the graft and the dowel. This particular screw is a new screw called the FastThread Bioabsorbable. You can see it lives up to its name. Okay, so now we cycle our graft and fix our tibial side. So we fix our knee in extension. Again. The interference screw can fix both the dowel and the graft. It's important to get your guidewire out before you finally put the screw in. Otherwise, I've broken many a guidewire. Two finger tight. Nice fixation. Great, Lockman. [00:13:07] There we go.

J. Lee Pace, MD (Farmington, CT), discusses graft options for ACL reconstruction and the benefits of quadriceps tendon grafts.

Alternative ACL Graft Options: Quadriceps Tendon

So, contrary to popular belief, the quadriceps tendon is it's actually a fairly well described graft that's been around for a long time. I think as we're all aware, it's been used fairly sparingly in a historical fashion, but it is definitely the hot topic nowadays. You know, my number I have here is, you know, up to 11% of ACL grafts, but, I mean, we may be even getting closer to 15 to 20% at this point of all autograft options with the quad. The reason why this, why the quad has sort of been the forgotten graft is due to sort of an unfair showing in this old 1984 biomechanical study where the quad got lumped into this what's called substitution graft, where it was a combination of, like, prepatellar fascia and patellar tendon. I mean, of course, that's going to fail. And so the BTB and hamstrings had a much more favorable biomechanical profile. And so the quad got equated with not good. So off people went with the BTB and the hamstrings for autograft options for ACL reconstruction. Well, in the late 90s, people started looking at the pure quad tendon and its biomechanical properties. And there's a couple of studies here that are that are mentioned. But the summation of these studies showed favorable comparisons to the patellar tendon, especially higher load to failure, lower elastic modulus, and significantly more collagen than the patellar tendon. And then in the last 20 years, there have been several favorable clinical reports. And John Fulkerson you know, the Fulkerson AMC was actually one of the first guys to publish on early clinical results from all soft tissue quadriceps tendon. And he showed here you know, fantastic stability, good patient, reported outcomes. And this is followed by further studies looking at bone plug on the quad tendon. A good again, good patient reported outcomes. Great. Great stability. Low donor site morbidity, and Fulkerson also published this article showing that the early rehab with the quad tendon was better than the other grafts. They were able to get their range of motion back quicker. They were off pain meds earlier, especially compared to the patellar tendon harvest. So what are the advantages of the quad tendon? This slide is the summation of a lot of studies done recently by John Xerogeanes in Atlanta, who has really popularized the quadriceps tendon and really sort of brought it back online for everybody. But in short, you're getting almost triple the amount of intra-articular collagen compared to the patellar tendon. You get a very predictable length and volume, significantly less donor site morbidity, even less than the hamstrings, equivalent to superior biomechanics and comparable to superior outcomes compared to the other two autograft options. And now with technology through Arthrex, a much smaller, much more cosmetic harvest incision, which was honestly one of the big things. So what are the other advantages? Well, it's very customizable. So if you love bone plugs, you can take a bone plug off the patella, and this can allow you to get up to 100mm of graft. And if you're all soft tissue, if you've got someone who's at least I believe it's like five eight, you can almost reliably get 80mm of graft. So you can customize whatever length, whatever technique you want with this graft. It's fantastically versatile and it's the versatility continues into skeletal maturity or immaturity. Excuse me. So for a standard skeletally mature patient, my preferred graft length is only about 60mm. I put about 15mm in each graft socket. If I'm going to do a hybrid technique where I want to cross the tibial apophysis with soft tissue to keep that open, I'll take a little bit longer graft. And if I do say, you know, a 10 or 11 year old kid and I go all epiphyseal, then I'll harvest a 50 millimeter graft so I can use any graft length that I need or want for the exact technique that I want, so I can use it in any age group. Okay. And if we look at the anatomy of the quad tendon, you can see it's huge. It's by far the biggest tenant in the knee. It averages about 70 to 80mm long. It's about seven millimeters thick. And you can see this is, you know, a rough representation of what a 60 millimeter graft harvest would look like. John Xerogeanes showed that you take less than 50% of the quad tendon with an 80 millimeter graft, versus 65% of the patellar tendon with a standard ten millimeter wide graft harvest. There have now been several comparative studies looking at the quad tendon versus either BTB or hamstrings. And in summary, all these studies show equivalent patient reported outcomes, equivalent retear rates, and equivalent to superior patient reported outcomes. And this is looking at all age groups across the board. This was the most read article in AGM last year. Was this systematic review and meta analysis of the different grafts? And again it showed what I just said that BTB versus quad, no differences in patient reported outcomes or objective measures. The graphs had similar failure rates. The quad had significantly less donor site morbidity than the BTB and significantly better. Patient reported outcomes. Functional outcomes than the hamstrings. Okay, so what about donor site morbidity? This is the this graph here has the least donor site morbidity profile of the other graphs. There have been literally a couple case reports in the literature of late quad tendon rupture. So there's been like 1 or 2 reported that we're aware of. And an overly aggressive graft harvest, if you get trying to get like a 80 plus 90 plus millimeter, all soft tissue graft, you can sometimes detach the detach the rectus femoris which is a cosmetic issue. And usually with all-inside, you don't even need to get anywhere near that. And obviously, anytime you harvest a bone, block off the patella, you do risk patella fracture. So I'm all soft tissue. I haven't harvested a bone plug in, I don't know, 4 or 5 years. And then the large scar is historical, I think, now with with current technology. So my question to you guys, is BTB really the gold standard for ACL reconstruction, and if it is, then the quad is the platinum standard. Right. So here is the instrumentation for quad tendon harvesting. You have a a graft cutting guide as well as a quad tendon stripper slash cutter. So I'll walk you through my harvest technique. I now do horizontal incisions. But you can see this is my old vertical incision here. This is less than two centimeters in length. And here's my my horizontal incisions now okay. Make an incision dissect. You basically kind of create a degloving injury. You get all that soft tissue off the off the quad tendon, get a Joker or something like that. Just sweep everything off. And then what I do unique, a little bit different than the technique guide is, I will actually use the arthroscope. I'll stick it up into the incision, and I'll place my cutting guide proximal where I want my harvest to end. And that way, I know that I'm between the muscle bellies. I'm not going to, you know, veer off and go one way or the other, and then I'll pull back, and then I'll go back and forth, back and forth, back and forth to complete my side cuts. It's a very reliable way. When I teach my fellows, it gives them a lot more confidence in doing this harvest when they start off in practice. And then from there, I will elevate it off the insertion, off the patella, usually with some Metzenbaum scissors. And then from there, once I have it elevated up enough, then you use the stripper cutter. It's graduated. So it tells you exactly what length you're harvesting. So I'll just push it up until I'm at 60, 65, and then I'll squeeze and detach and out it comes. Just like that. Click okay. The next step is prep. I would say if there was one knock on the All-inside quad tendon graft prep, it was that it was a little bit of an onerous graft prep. You needed to have a capable assistant to do this for you. Now, Arthrex has made a FiberTag with the TightRope attached to it. So I'm a very fortunate person. I have the world's best physician assistant. He would have my quads prepped the old way, typically by the time I was done drilling tunnels. Now I'm getting the femoral tunnel done and he's coming up to help me with the tibial tunnel. This is how fast this FiberTag TightRope is made. Graft prep. So here's a little video. There's a special clamp, and you have a FiberTag TightRope on this backer card that you can then then pass the whipstitch through with this really robust, strong Keith needle. And as you do your whipstitch, as soon as you're done, you've already got your TightRope attached. So that's it. It's it's really literally cut our graft prep time in half. So it's like under ten minutes to put to prep this graft at this point. Okay. And you guys will get a chance to play around with this today. Tunnel preparation I again I'm all-inside. My most common graft size or tunnel size is a nine and a half. I'm not accommodating bone blocks. I'm I'm accommodating collagen. Okay. So this is just a huge graft. And now with the FlipCutter three again here's a picture of this. You guys get a chance to play around with this today. As you said, it's an all in one RetroCutter. And then here's an example of my tibial tunnels. Fiberstick TigerStick just like Jason said. And then graph passage, just like they said, pull it through the the medial portal. You know, I mark my my middle 30 of the graft, dunk my femoral side, dunk my tibial side. And then from there then I'll adjust. I'll usually under pull in my femoral tunnel so that I can then make that final adjustment. You can see me just adjusting the femoral tunnel up to the purple mark right there and done. And similar to Jason here is what my implant, my x rays look like. You know, all-inside TightRope PT on the femur, abs TightRope on the tibia and then post-op a straight up ACL reconstruction without meniscal work, without additional work weight. Bear motion is tolerated. Crutches for comfort. Similar graft rehab. You can see. Here's what the incisions look like. Here it is relative to a water bottle. And then here we are going horizontal now, And you can see just and these are like three months, three month post imaging photos here and these things disappear okay. Pretty fantastic. So the other thing that I really love about the quad is it looks to mature quick. So Freddie who's looked into this and he's shown that compared to the hamstrings that if you look at post-surgical MRIs that the quad tendon tends to go dark i.e. mature quicker than a hamstring. So this is one of my patients at five months out with that's that's what her ACL looks like five months out. Is that just cable of dark homogeneous tissue okay. And if there was one thing about the quad is that, you know, sometimes it may be too big. John Xerogeanes published he's got about an 8% risk of Cyclops lesions. And Freddie Fu published that the quad compared to the hamstrings, actually may tend to sometimes overstuff the footprints. So you know, I'm very I don't need to get a 1011 graft on this. I'm very happy between, you know, around nine. I'm, you know, in my smaller kids, if I If I get an eight and a half, I'm, I'm I'm more than happy. So then if we look at some of the SOS data, you can see again equivalent SOS scores on SOS. Here visual analog scale activity scores here looks great. Okay, so future directions, you know, as far as the QuadCore is concerned, routine internal bracing, I actually do that in every single one of my ACL reconstructions now and then, as Jason mentioned, biological augmentation. There's actually a recent arthroscopy techniques article in which Chad Lavender uses the GraftNet to collect his tunnel drillings and then fertilizes his tunnels even further. So there's a lot of continued work we can do to continue to augment our our ACL reconstructions. I would say that QuadCore at this point has become probably the preferred graph for more and more people on a daily basis when it comes to Autograft ACL reconstruction. Thank you very much.

Seth L. Sherman, MD (Redwood City, California), presents a two-stage revision ACL reconstruction case. In the first stage, Dr. Sherman performs a bone graft procedure in both the femoral and tibial tunnels using allograft bone dowels soaked in bone marrow aspirate. In the second stage, he performs a revision quad tendon autograft ACL reconstruction along with a lateral extra-articular tenodesis. Finally, Dr. Sherman shares pearls and considerations for planning complex, multistage revision ACL reconstruction procedures.

Two-Stage Revision ACL Reconstruction

Hi, I'm Doctor Seth Sherman from Stanford University, and this is a case presentation evaluating two stage revision ACL reconstruction. The patient's a 37 year old female. She's a recreational athlete. She had a non-contact ACL injury. She underwent a primary ACL reconstruction with partial meniscectomy at an outside hospital. She had insidious recurrent instability and pain, beginning a year and a half later prior to presentation in my office while seeing me. She had range of motion. That was ten zero 140, so ten degrees of hyperextension, which was symmetric. She had a twoby Lockman and what we call an explosive grade three pivot shift. She was stable and symmetric to varus and valgus stress. Her dial test was symmetric, and her opposite knee had a physiologic pivot glide with an intact ACL on her preoperative X-rays that are weight bearing. We can see that there's no significant joint space narrowing. There's concern for significant cystic changes in both her tibial and her femoral ACL tunnels. We always get other views, including long leg mechanical axis, which in this case show neutral alignment. And we do weight bearing lateral x rays of the knee and or tibia to evaluate for tibial slope, which in this case on x ray was measured to be 13 degrees. We have MRI which showed intact menisci collaterals and cartilage but obviously those dilated cystic femoral and tibial tunnels. We do like to do 2D 3D CT scans in these challenging cases to evaluate both for tunnel widening and tunnel positions. In this case, these tunnels were obviously wide and above our thresholds, but the tunnel positions were good and the tibial slope was measured at 12 degrees. Other information that's critical is to think about and to rule out infection. She had no fevers, chills or sweats. Her vital signs were stable. Her wounds appeared benign. She had an infectious workup, including aspiration and culture. She had laboratory values including CBC, ESR, CRP, which were negative. And we also look for and think about this intraoperative in our first stage of our revision reconstruction. Arthroscopically. When we got in there, there was mild synovitis, no signs of infection and really minimal chondrocytes. She had intact medial meniscus root. We always have to look for ramp lesions in these complex chronic or salvage cases. Lateral meniscus had only a white white tear with an intact root as well. Here's look at the femoral tunnel, which was measured to be 14mm. And the tibial tunnel diameter was measured to be 16mm. It's always useful to make a problem list. So here we have our 37 year old. She's a recreational athlete. Insidious failure of her prior ACL allograft. We think to ourselves, why did this fail? What can and should we do different this time around? Is it graft choice? Is it issues with her tunnel? Is it underlying hyper laxity. Missed malalignment meniscus deficiency other or a combination of all these factors. Should we do a one stage versus two stage. If it's two stage, what bone graft are we using? What concomitant procedures might be helpful for these other structures. And of course setting goals and expectations in rehabilitation and recovery for this lady. We moved forward with a two state solution. Given the size of her tunnels, we can see here in the first stage we use the Cannulated revision allograft dowels. We can mallet them into final position, and then I find it very useful to PoweRasp, and we can counter them so that they are flush to both the femoral and tibial aperture. Can see here that these allograft dowels are soaked in bone marrow aspirate concentrate. We have a separate video showing ways that we can take bone marrow aspirate from the distal femur and or the proximal tibia. Or of course if it's your preference you can go upwards towards the hip. I think it is also helpful to consider, as we see on the far right, mixing AlloSyncPure with bone marrow aspirate concentrate. If there are any gaps in your bone grafting or severe enlargement of tunnels even larger than our biggest dowels, then we can fill those gaps and seal the apertures more precisely using this AlloSyncPure mixture. And so here we see our final fluoroscopy after the bone grafting of both the femoral and tibial tunnels. For me I like to weight bearing as is tolerated. They can bend the knee as tolerated with a functional brace. I typically track these by X-rays. Rarely do I use CT scans in the case of these allograft dowels, and I usually can return to the operating room as as early as three months for my second stage reconstruction. In this scenario, we're moving towards a revision ACL using quadriceps autograft and a lateral extra articular tenodesis with iliotibial band autograft. Some tips or pearls that might be somewhat different than others. I like to do a non sparing quadriceps harvest, so I can use the QuadPro similar to how the technique is demonstrated, but I leave that most anterior aspect of the non intact. This allows me to go full thickness with my graft, but I really have very little to close and it maintains continuity between the medial and lateral aspects of the residual quadriceps. As you see here, here we can see preparation on the back table of our QuadLink with internal brace. I am always soaking in vancomycin, and I'm always pre-tensioning my graft on the back table before bringing it towards the patient. Another tip or trick for doing ACL and let to avoid crowding of those tunnels. Here you can see we're using A26 knotless FiberTak. And what I wanted to point out is where the arrow is. I'm leaving my femoral pin in place while I'm placing the FiberTak. That way, if there's convergence, I can just redirect. I make sure that my soft suture anchor is well positioned and firm, and then I can pass my femoral shuttle stitch. This alleviates a lot of anxiety in the operating room for me. You can certainly also look with the camera arthroscopically through the medial portal into that femoral tunnel to ensure there is avoidance of that FiberTak at this step. And then otherwise we do the IT band Bio-Tenodesis as shown here. This is the final revision. Quadriceps Autograft with physiologic tension without graft or notch impingement throughout the range of motion arc. Some things that I consider when planning these difficult two stage revision ACL reconstructions. The first, as we mentioned, was thinking about tunnel and tunnel diameter and position. We use the 2D CT scans to quantify tunnel enlargement, typically using 14mm as our cutoff for action. Here you can see why the two DS are quite useful. For this purpose. We use the 3D reconstructions a bit differently. We really are looking for tunnel position. We can overlay the Bernard Hartel grid if you so choose, and we can envision a couple of different scenarios, like this case where the tunnel is not terribly wide and in good position, and we can do can do a single stage revision reconstruction. However, there are other cases like this one where that prior tunnel is way out of the anatomic position, and we can clearly and easily do anatomic ACL reconstruction in one stage. However, there are other times where we require either single stage with some tips and tricks like larger bone blocks or blocking screws, and that can get technically difficult. Or we can lay up and do a rational two state solution, like the case that I showed today. Another tip or trick that I think is important is graph choice for revision. I almost exclusively am using Autograft, and I think quadriceps have begun to really become the mainstay of treatment of for me for these types of scenarios. In this paper, Autograft is 2.8 times less likely to rupture with superior subjective scores and activity scores at two years, so please consider Autograft Autographed revision. If you can hear, there is obviously a growing set of data for quadriceps autograph, not just for revision ACL, but also for physio sparing ACLs and also for primary ACL, which rivals our gold standard. Other graphs choices such as BTB. We always want to evaluate and protect the ACL graph by preserving the meniscus if at all possible. In this case, we did not have roots or ramps or complex meniscus tears to go by, but certainly we want to on the side of meniscus preservation. It can only make your outcomes better. We all know about the clinical relevance of tibial slope. The first step is to measure precisely and to understand our cutoffs, which are about 12 degrees, where slope might become something that we consider fixing or using as a modifiable risk factor. And perhaps if you're on the fence adding something like a lateral extra articular tenodesis to your revision or primary ACL. Here is how we can measure the tibial slope on x ray and or MRI or CT with that 12 cutoff. And then lastly we're thinking about anterolateral rotatory instability. And we're thinking about ways to protect our ACL outside of the joint. There is a very strong evidence base now for adding lateral extra articular tenodesis. The workhorse is using iliotibial band autograft. And I use that generously in patients with many risk factors and certainly in the revision setting. So I thank you very much for your attention, and I hope that this case presentation on two stage revision, ACL reconstruction will bring up some tips pearls that are useful for you in your daily practice.

Walter R. Lowe, MD (Houston, TX), presents a case during which he used the FlipCutter® III drill for a revision ACL reconstruction.

Revision ACL Reconstruction Using the FlipCutter® III Reamer

I'm Walt Lowe from University of Texas in Houston, Texas, and this case presentation is about the use of the FlipCutter three patient history, very typical for a failed ACL. So this is a revision ACL. Her symptoms were both instability and a mechanical locking symptom coming from flexion into extension exam. Again a very typical exam. Important to note that all signs of instability related to the ACL. And on our imaging she had a slope of 12 degrees. Typical imaging in a revision setting for me is plain X-rays and long leg standing films, where you can calculate an accurate slope. This video shows preparation of the femoral tunnel. You can see bone grafting of the old, very vertical tunnel up above it, using an awl to establish the location for where I would like to place this new femoral tunnel, not close to the old one. Obviously, the more rigid FlipCutter three makes it easy to just raise your hand a little bit and then come into the spot you want to establish your femoral tunnel. This was a ten millimeter femoral tunnel, and you can tell as we deploy it the clicks. You can just deploy it to the size you want, anywhere from six millimeters to 12 by half sizes at every step. Technique I like to use is to establish a small footprint right there saying I like what I see, and then drilling the entire tunnel up to the depths that have been previously calculated. And then click back down to the three five and you can pull it out easily. Follow it with the FiberStick for passing your graft into your tunnel. In reviewing the FlipCutter three, it has really changed the ability to have a device there that you can address any tunnel you need to drill, whether it be tibia, whether it for an ACL, tibia for ACL, femoral for either one of those two also, and for root repair, medial and lateral only opening up one device per case. And that device can be waiting on you even while preparation is happening for soft tissue grafts. Those things, you know, the new length allows reaching those tunnels, and the variability allows decision making and even changing tunnels as you go. The final utilization can be in revision settings where you are using old tunnels. You can sequentially prepare those tunnels by gradually increasing the size of the FlipCutter until you get to a good, bleeding, healthy tunnel for graft. Reimplantation.