Collateral ligament reconstruction requires the use of the patient's own tissue or cadaver tissue to reconstruct the injured ligaments on the medial or lateral side of the knee. Historically the decision process to reconstruct or repair the ligaments or tendons is dependent on the location of the injury (medial or lateral structures) and whether the injury is acute or chronic. When the decision is made to reconstruct, the procedure can be performed with minimal or extensive exposure depending on the desired reconstruction technique. The Collateral Ligament Reconstruction Set, pioneered by Arthrex and surgeon consultants has been specifically designed to improve the safety, accuracy and reproducibility of these complex multi-ligament reconstruction procedures.

Knee

Procedure

Once the minimally invasive or open incision is made and proper soft-tissue windows are established, use the fibular, tibial, and/or femoral collateral marking hooks for anatomic precision and osseous measurements when drilling the appropriate reconstruction tunnels. Using the femoral collateral marking hook with the parallel drill guide will increase anatomic femoral drilling efficiency by significantly reducing convergent tunnels and allowing for accurate guide pin placement at multiple incremental distances. During tunnel creation, use the spooned ends of the collateral ligament retractor to retract the neurovascular structures and the collateral ligament rasp to chamfer the aperture of the completed reconstruction tunnels. Then use FiberWire® or FiberStick™ suture to pass the prepared grafts and tension to the desired position prior to graft fixation.

Armando F. Vidal, MD (Vail, CO), demonstrates a posterolateral corner reconstruction using the FiberTag® TightRope® implant.

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Posterolateral Corner Reconstruction With the FiberTag® TightRope® Implant

Today we're going to present a lateral collateral ligament and posterolateral corner reconstruction utilizing a modification of the Arrow technique. In this video, we're going to use a free soft tissue graft coupled with two FiberTag tightropes on either side. We feel that the FiberTag TightRope for this application allows for a very reproducible tensional technique for lateral posterolateral corner reconstruction. For those of you unfamiliar with the FiberTag TightRope, the FiberTag comes preloaded on this card, which allows for a much more rapid and reproducible preparation of the graft. The FiberTag, as you see here, is loaded on this card and on a corresponding graft clamp. The graft clamp is the perfect length for the card and comes essentially fixated to the card. The FiberTag, which essentially is this large, flat suture, is going to be stabbed by the FiberLoop, which creates essentially this ripstop construct, which is a much more reproducible and And biomechanically sound construct than are typical techniques, which would involve a variety of locking sutures which are then tied to an adjustable loop. So what you're seeing here is again, we're taking the FiberLoop, passing it through the suture, through the FiberTag and through the graft, and then pass through the card and then back up through the FiberTag. We will ultimately do this on both sides of the graph. So we will have two adjustable loops on either side of this graft. Additionally, you can supplement this fixation with an internal brace. We're going to run an internal brace in this case from the femoral insertion fibular collateral ligament to its fibular insertion. We can see the entire construct. You see the FiberTag TightRope on the femoral side preloaded with our internal brace, our FiberTag TightRope. That's going to go through our fibular head and into our popliteus insertion with our second FiberTag TightRope there. And now we'll go to our dissection and our reconstruction. So we're looking at Gerdy's tubercle here. Lateral epicondyle here. Fibular head over here. And then we're going to estimate where the peroneal nerve is going to come. This can be done through a variety of different incisions I prefer the more extensile hockey stick incision. We're going to start just distal to gerdy's. Come right behind gerdy's essentially over the lateral epicondyle. And then in line with the femoral shaft. I'm going to create a posteriorly based flap as described by Doctor Laprad. And that's going to be your surgical dissection tunnels here. And then obviously fibular tunnel here. So we're going to follow this back until we see the biceps femoris. First thing we're going to do is we're going to dissect out the peroneal nerve. You're going to see it band. You're going to see muscle belly of the biceps femoris. You're going to see tendon of the biceps femoris. And we're going to come behind the biceps femoris to dissect out the peroneal nerve. I like to do this with debakey's ideally, just so I don't like to have to forceps as we're dissecting out the nerve. So the nerve we're going to see here in this fat again, you have the tendinous portion of portion of the biceps here. We're starting to see the nerve in there once you have exposure. We're going to dissect it and we're going to do a peroneal nerve neurolysis for all these cases. Because it's a cadaveric specimen. There's no proximal attachment. This nerve does tend to sag back a little bit more so than it would in a live specimen. And it's usually also much more visible in a live specimen as well. So we're going to expose the insertion side of the fibular collateral ligament on the fibular head. This again is the biceps femoris. We're going to make a small horizontal cut. In line with the fibers of the biceps femoris. We're just going to dissect down. Then we're going to see the native fibers of the fibular collateral ligament through that window. You can see it right in here. The benefit of this is we can then tag it with a number two FiberWire suture. This will allow us allow us to place it on tension and allow us to help identify the insertion sites. On both the fibular head and on the femur. So we're just going to tag that. Perfect. And that gives us control. And as we pull it down on this we can feel it on tension. The fibular collateral ligament there on tension. And we can follow that up to its insertion site on the femur. So that's going to give us control. Just a little pearl that makes things a little bit more reproducible. So as we pull on it again I can feel the insertion site on the fibular head is anterolateral. It's not straight front to back. So our ultimately our tunnel is going to go from anterolateral to posteromedial. I've got perfect exposure. I can feel I've dissected the muscle off the back. So we have that window completely exposed at this time point again. The second window is the window between the IT band and the biceps femoris. That's going to be a meniscal repair window, which is not necessary. Next part is we're going to expose our insertion sites on the femur. We're going to start pretty much at gerdy's And follow this up. All the way proximal. This will be closed at the conclusion of the case. So just anterior to our fibular collateral ligament we're going to make about a centimeter half a centimeter off. We're going to make this little vertical arthrotomy. Again. At this point you would lose all your arthroscopic fluid. So I would advocate that you wait to perform this portion till you're done with your arthroscopic portion. But you can see we're in the joint. Now, if I wanted to, I could pop this in. You can see the the edge of the lateral condyle. We know the insertion is about 18mm off. It's going to be distal and slightly anterior. You can follow the popliteus. So the popliteus is right here in my retractor. So again fibular collateral ligament here popliteus here. And we're going to follow that up to its insertion site which is going to be about there. So FCL and then popliteus here. So this guide here is part of the Arthrex multi ligament set. Essentially you can you can see it has a contained capture in the back. It also has markings on the side to give you a sense of how long that fibular tunnel is. The fibular tunnel should be about 2025 in length on average. It can vary a little bit by individual. You can feel it if you don't have a lot of experience doing these. I think it's very reasonable. After you place your Pin to go ahead and check it with x ray, just to ensure that you're not too proximal in the fibula, you're not too lateral in the fibula, so you don't blow out as you place your tunnel and then ultimately your screw. We have our muscle belly, the latter head of the gastrocnemius. We're going to come around the back again. Our tunnel is going to go from anterolateral. So we're going to follow that FCL the FCL inserts here. We're going to stay anterolateral. And we're going to aim for posteromedial back where the fib ligament comes off. So we're I was saying it should be about 25 to 30. I'd say right now we're measuring right at 30. All right. On a retractor there. Perfect. Guide comes out. Perfect. Coming out right where the pop ligament comes out. We're then going to ream that. Ideally about a seven millimeter hole. Always something in the back to protect the neurovascular structures. And then we'll place a passing stitch around there. So we're going to use a FiberStick to pass it through. We're going to go from front to back. Again always something in the back to protect. Can you see that. Perfect. And then we'll snap that. Excellent. Again always being mindful of where the perineal nerve is. Very safe there. We're going to go back up to our femoral insertion sites. You can mark it with a bovie. You can mark it with a marking pen. So again lateral condyles are my finger areas are going to be just proximal and posterior insertion sites going to be right around there. You can follow the native anatomy. Again. You can see that pretty readily. This can be done with a guide. It can be done freehand. Ideally you want. So we're going to use a spade tip that will allow for perforation of the far cortex for passage of our button. We're going to shoot anteriorly and we're going to shoot. So it comes out just proximal to the medial epicondyle and the adductor tubercle. If you aim it anteriorly and proximal to the medial epicondyle and the adductor tubercle, you should be able to avoid your ACL tunnel, as that's commonly what you're doing this with is with a concomitant ACL reconstruction. We're going to put it right there in the footprint. Again we're going to aim. This could be done with a guide. It could be done under image guidance or freehand. We're going to aim it slightly anteriorly. So I'm dropping my hand I'm aiming it medially Right in the native insertion. With the spade tip, we'll be able to directly measure off the pin. We're going to perforate that far cortex. And then we can pull it back to measure. This one's measuring 70 exactly as I pull it back. That's pretty typical. We need to know that measurement for flipping of the button. Once we get the determination of the interosseous length, we're going to send that all the way through. We know based on anatomic studies, that it's approximately 18.5mm from the insertion site of the collateral ligament to the popliteus, you can see right where our insertion site is going to be. I'll mark it out with a pen again, just for clarity. You can palpate it just off the articular margin. It feels like it's right there off the articular margin. Again, for measurement purposes and illustrative purposes, you can see we're right around 1817 18mm. Millimeters. Almost. Exactly. We're going to drive this pin similarly. Spade tip pin. Once again we're going to put it in that same spot. We want to keep it parallel to our first pin again exiting just medial sorry just above the medial epicondyle. And aiming anteriorly. We're going to drive this all the way through spade tip pin. We'll pull it back once again just to get intraosseous length. This one's also measuring right around 70. And then we'll drive it through. Just to finish. You can see them coming all the way out. We have a little bit of convergence on the way out. I don't think that that's really a problem. You can see our two tunnels and again, if you show me a ruler, there's that little paper ruler we had. You can get a pretty good sense of how far apart. I think the one advantage of an all soft tissue graft as well is we're not going to have a big tunnel for a bone block, and we're not going to have a screw as well, which also occupies space. And a lot of these cases you have an ACL femoral tunnel, you have a popliteus tunnel, you have a fibular collateral ligament tunnel. You have quite a bit of holes in real estate in there. So it minimizes how much real estate you're occupying with these graphs. So we're pretty much ready to go. So we're gonna go ahead and drill these two. I like to over drill these. And the benefit of that is you don't bottom out the graft accidentally. We'll drill our FibuLock lateral ligament. First I'm going to drill these to a depth of about 40 or 50mm. It's more than you need. But again you don't want to go through all this and then bottom out a graft in a tunnel and not be able to complete your tensioning. At this point. If I had an ACL reconstruction as well, I typically would have drilled my ACL tunnels. I'll actually put my scope in and just ensure that these pins. I can't see these pins in my ACL tunnel to minimize the risk of convergence. Thank you. We're going to drill. To about 40. This one's also going to be drilled to about 40 or 50 again just for redundancy. All right. And then let's get another passing stitch. All right. Go ahead. Perfect. All right. So now we're going to go back to our graft. So we're going to pass the side with the InternalBrace first through our femoral tunnel for the FCL. So we're going to go ahead and shuttle that. So the InternalBrace construct is going to stay with us and the graft. So just again for illustrative purposes InternalBrace is going to stay with us. We've marked out on the TightRope the interosseous length that we measured off that spade tip. All right. All right. Go ahead, pull it through. I'm going to give you some kind of resistance. We're gonna go to the mark. I'll let you know. Keep going. You may feel it before I do. So we're right about at our mark. As with any suspensory fixation, I'm giving a little bit of counter resistance so we don't go too far. There we go. And I'm going to pull it just a touch more. There you go. And I'm going to pull back. Nope. There we go. All right. There we go. Now we're fixated on there, right at our length as we measured off our spade tip. And again, we have these internal brace construct that's going to essentially serve as our internal brace for our fibular collateral ligament. So we're going to go ahead and tension that down just a little bit just to get this thing recessed and to give him a little bit of counter pressure. We're going to sink this in about 20mm. If you recall we drilled this to about 50. There we go. Perfect. Go a little bit further. Just a touch. All right. Perfect. So now we're perfectly fixed in there. Very solid. I'm pulling almost with, you know, probably 20, 30 pounds of tension. That thing is not giving it all. So the last two steps we need to do is we have to have our passing stitches to get them through our tunnels. So we're going to hold that. Let me see a snap and a FiberWire. As you can see, the fibular collateral ligament here, the last two steps is we need to create our passage for our graft along the course of the collateral ligament and along the course of the popliteus. So we're going to essentially go along this course deep to the IT band, deep to the biceps femoris. So we're going to pass it along in here. And it's going to come out just like that passing stitch. You could just pass a Kelly and just do it directly. This will just illustrate it better. We're going to pass the entire construct. Everything is going to come with us button included. That's going to come Through, including our internal brace. You can see the internal brace next to our graft. We already have our passing stitch for our fibular tunnel. We can actually remove our stitch through our fibular collateral ligament at this point. We don't need it anymore. So now we're going to pass it again from front to back. I'm going to pass that through. Go ahead and shuttle. You just need to make sure the button goes in along its axis so it doesn't get stuck. Go ahead and pass it through. Our fibular collateral ligament is now passed. And then our last step is going to be to create the passage for the popliteus. So we're going to come behind our graft along the course of the popliteus along the popliteal hiatus. Let me get out of your way so you can see it. You want to put a finger back there in general just to protect the neurovascular structures. I think there is utility to dilate that up just to make graph passage easier. Pass that through. Last step. Pass that through. Excellent. And that should go pretty readily. We'll then pass our popliteus. Go ahead. Give him a little bit of resistance as far as I can. So now we can cycle the knee through. We've got both both sides fixated. They're both still relatively loose. We have our internal brace on this side. We're going to cycle it through a range of motion. We're going to do our internal brace now. And we're going to do final fixation on the fibular head and then do final tensioning using our adjustable loops. Neutral rotation valgus load applied. So we bring the eyelid up. We're going to mark it at the level of the screw just so we don't we don't over tension the InternalBrace we're going to bring the eyelet back to that level. We're going to bring that leg into position. Go ahead and hold the leg for me. We're going to engage it into the tunnel. Light taps just to engage the screw. Again we have not done final fixation on our graphs yet. There's still a little bit loose. We will do that with our suspensory fixation. We're going to bring this down. We're now locked. So the graphs are now independent. You can see a little bit of tension in our internal brace. Perfect. The suture is no longer needed. Again we can cycle the leg now at this point. Final fixation is going to occur in our two graphs independently using our FiberTag TightRope. So for the fibular collateral ligament going to bring the knee in about 30 degrees of knee flexion. Neutral rotation Valgus load applied. Let's go ahead and pull tension on that. And we actually have pretty good tension already for the Popliteus. Cycle it again bring it down to about 60 degrees neutral rotation. So now we're going to tension our popliteus. You can see it advancing in on that position. And now it's pretty tight. You actually see it under quite a bit of tension here. This craft is great cycled through. And then we have our internal brace here as a backup. So that's our final configuration. Again this is a modification technique using suspensory fixation and backup with an internal brace. So closure again ensure that the vessel loop that was placed around the peroneal nerve has been removed. No sutures around that. We will close the IT band in line to cover the femoral insertions. Put actually put a vehicle if you want to close the arthrotomy as well. And then a layered closure as per typical protocol.

John David Adams, MD (Greenville, SC), demonstrates an anatomic posterolateral corner reconstruction using the FiberTag® TightRope® implant and the InternalBrace™ technique. This procedure anatomically reconstructs the fibular collateral ligament, the popliteus tendon, and the popliteofibular ligament.
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.

Posterolateral Corner Reconstruction: FiberTag® TightRope® Fixation Using InternalBrace™ Technique

I'm JD Adams and we're going to be demonstrating a posterolateral corner reconstruction. The anatomic technique with all FiberTag TightRope fixation as well as internal brace augmentation to begin with the dissection. One of the more important things. A lot of times we'll use a triangle to support the leg. And one thing I've found is that you don't want to have the leg supported on the tibia side, you want the triangle to support the femur. That will allow the peroneal nerve to kind of fall backwards and give you more room to work on the posterior aspect of the fibula and the tibia. So what I've done is a normal dissection here. One of the first things you do is identify the biceps tendon and then right posterior to that you'll find the peroneal nerve. It's really important to free that up all the way down to the neck of the fibula, and make sure that you've got plenty of mobility of that peroneal nerve so that you can get to the posterior aspect of the fibula, and then also be able to work to the backside of the tibia, because that's going to be important for this anatomic technique, to be able to get back there, to be able to drill your popliteus socket as well as your popliteal fibular ligament socket. The next thing we do is identify the isometric point on the femur. A lot of times I'll use fluoroscopy to identify the isometric point using the posterior femoral cortical line. As it intersects blue line, make an incision through the T band. And then a lot of times I'll actually put retraction stitches in the T band to be able to give me more room to work. In this case, I've actually put in number two FiberWire in the LCL to be able to put traction on it to identify the isometric point here. And as we know, the Popliteus inserts approximately 18mm anterior and distal to the LCL. And so if you make a longitudinal cut in the capsule here you can see the popliteus insertion. And as we expect the popliteus is inserting approximately right here. And that is indeed approximately 18mm anterior and distal from the LCL insertion. This is quite a small leg, so it may be closer to 17mm, but nonetheless it's very close to that 18 millimeter mark. And so we'll be using both of those for our femoral sockets for the Popliteus and the LCL. This is a really nice tool that Arthrex provides in their collateral ligament set. It provides retraction of the soft tissues posteriorly to be able to get to the posterior aspect of the tibia, and to be able to protect the neurovascular bundle posteriorly as you drill from anterior to posterior in the tibia. And we'll be demonstrating that with the FlipCutter technique. With this all TightRope fixation technique, the other instruments we'll be using is the different guides out of the collateral ligament tray. So this is the tibial collateral ligament guide. And so this will be going on the posterior aspect of the tibia. And then guiding us from anterior to posterior. The other guide that we'll be using is the fibular guide. And as we know the LCL inserts on the anterior lateral aspect of the fibula. And so there's always a small bump right here on the fibula that you can hook this guide on. And then aim from anterolateral to posterior medial on the fibula. You can always check this on fluoroscopy to make sure that you're distal enough to make sure that your socket or your tunnel is not too proximal and potentially cause a fracture. This also provides you the tunnel depth to make sure that you've got enough depth. Another alternative technique that can sometimes be used is actually to put your finger on the posterior aspect of the fibula and actually drill towards your finger, and then overeem that drill with the size of the tunnel that you have specified. The other option is to put your finger on the posterior aspect of the tibia and drill towards your finger there. I think both techniques are nice. Obviously you can injure yourself, so the guides are very helpful to prevent that. I think one thing you need to be careful of with the guides is to make sure to be careful when you're drilling. Very rare that they would miss the guide, but obviously you don't want to miss and go out the posterior aspect of the tibia, potentially injuring the neurovascular structures. So for this anatomic posterolateral corner reconstruction, using all FiberTag, TightRope wanted to walk through the way this is set up. So we begin on the tibia with a socket that allows us to be able to have two different allografts one that's going to be the popliteus that's going to go from the tibia up and around into the femoral insertion of the popliteus, and then another limb that goes through the posterior aspect of the fibula out the anterior lateral aspect of the fibula, and then back up to the LCL insertion on the femur. So for the graft preparation, we have two limbs, two allografts, that are brought together with a single FiberTag TightRope. So you have the LCL and the popliteus allograft, and these are brought together with a single FiberTag TightRope. Now on the tibial side, we've lengthened the TightRope to give us plenty of room to be able to dock our button on the anterior aspect of the tibia. We've also applied a trail stitch in the small hole of the button to help flipping the button on the cortex. Similarly, on the popliteus side, on the femur, we've attached a TightRope using the FiberTak TightRope, lengthen the TightRope for the femoral socket, and then also applied a trail stitch to help with flipping the button on the cortex. All right. The other limb of the graft is the LCL allograft. Similar fashion in the TightRope attached to the end of the graft. Using the FiberTag TightRope, we've lengthened the graft and then in this side, for the InternalBrace augmentation, we've attached the internal brace to the TightRope button and also applied a trill stitch. One of the major benefits of using all TightRope fixation is the ability to tension the graphs. And so we've got plenty of room on the tibia as well as the femur to tension the graph. So you want to make sure that you've got your graphs long enough to not bottom out in the sockets. And so in this case we've got a graph of about 160 to 170mm of graph for the popliteus and approximately 200 to 220mm of graph for the LCL and the fibular ligament. Obviously, this is dependent on the size of the patient, but usually these sizes work very well. All right. So we begin on the tibia for the tibial socket. In this setting we use the FlipCutter to be able to drill a retrograde socket from posterior to anterior. We use the tibial guide from the collateral ligament tray. This is then placed onto the posterior aspect of the tibia, and the guide is placed onto the anterior aspect of the tibia. A tibia. A small incision is made. The FlipCutter three is used to drill from anterior to posterior. All right, so once it's out the posterior aspect of the tibia, the FlipCutter is used to dial up to the size of the socket. In this case an eight socket was sized on the back table. We then engage the tibia with the FlipCutter. We had measured previously that we had a 50 millimeter depth, and we're going to drill this to approximately 40mm. Once it's engaged, we bring down the button. The FlipCutter is then brought back to its original size to facilitate passage back through. And then a FiberStick is used to pass through from anterior to posterior. And then this is just grabbed with a instrument. All right. Next we move to the fibular tunnel. This is drilled in the direction of anterolateral to posterior medial facilitated by the guides seen here. It's placed on the button of the back side of the fibula, and a small 2.4mm wire is drilled through the fibula. Using the guide. All right. So now the guide is coming out the posterior aspect of the fibula. A lot of times I'll use my finger to protect this back here. And then I'll over drill to the size of my graft, which in this case was a 6.5. So in this case, a six millimeter reamer is drilled over the 2.4mm guide pin. One thing you want to make sure is to fully penetrate the tenodesis reamer through the posterior aspect of the fibula, to clear off the soft tissue to help with graft passage. Once that's passed through, a FiberStick is used to facilitate a passing suture. Now we move to the femur. We begin on the LCL insertion. I've tagged the LCL to help identify the isometric point. The spade tip guide wire is inserted at the insertion and driven in a slightly anterior and slightly proximal direction. This direction helps to miss any ACL concomitant tunnels that may be in place. Once the spade tip is through the medial cortex of the femur. You can then pull back to get an intraosseous length. In this case, it's approximately 65mm and then it's drilled out the skin. All right. At 6.5mm tenodesis reamer is then placed over the spade tip. As we said before, our intraosseous length is 65. We want to make sure to not penetrate the medial cortex, but we also want to take advantage of the TightRope. So this will be drilled to approximately 50mm. Once the socket has been drilled, a passing stitch using the FiberSnare is used to pass through the spade tip. Leaving the loop end on the femoral side for the popliteus insertion on the femur. As we mentioned earlier, it's 18mm anterior and distal from the LCL insertion. Another alternative is to use the parallel guide that you can put over the pen, and then drill a separate pen that's parallel. That's 18mm away from the LCL. When I'm using sockets like this, a lot of times I like to diverge the pins. And so I do a freehand technique. So 18mm anterior and distal right here and then drilled slightly anterior and not quite as proximal as the previous tunnel. So it's important to realize when you're using TightRope fixation that you have to have a four millimeter hole on the opposite side to flip the button through. In this case, we did not use a spade tip, which is important, especially if you're using the parallel guide. So the first thing to do is Overeem the wire with a four millimeter reamer. Now we drill our popliteus socket on the femur. In a similar fashion, we drill this to approximately 40 to 50mm. Sutures are then passed out the socket and clamped. We begin with introducing our graft on the tibial side first through our passing stitch, protecting the soft tissues and posterior aspect of the knee. Your finger can be used to help guide the button and orient the button from a posterior to anterior direction. The button is then shuttled through the tibia and docked on the anterior aspect of the tibia. The graft is then brought into the tibia approximately 15mm. I then make a tunnel through the soft tissues using a tonsil or a hemostat for the popliteus. Once the hemostat is placed deep to the PT band and the popliteus graft is then passed underneath the soft tissues. Remember, the popliteus graft is the shorter graft of the two. A passing stitch is then placed underneath the soft tissues. And then using this passing stitch, we pass the graft. Popliteus graft is then shuttled into the femur using the passing stitch. Once the button is flipped on the medial cortex, a lot of times I'll confirm that by fluoroscopy. I then bring approximately 30mm of graft into the socket. The LCL graft is then brought through the fibular tunnel. This recreates the popliteal fibular ligament using the passing stitch that we previously placed through the fibula. A hemostat is in, placed underneath the soft tissues from the fibular head up to the femoral insertion, and a passing stitch is placed. This passing stitch is then used to shuttle the graft underneath the soft tissues. The graft is then brought into the femoral socket using the previously placed passing suture. We make sure to leave the internal brace behind. Once the button is flipped, the internal brace can be used to hold the button on the medial femoral cortex, and the graft is then brought into the socket. We then tension the popliteus in approximately 60 to 70 degrees of flexion. Slight internal rotation. You can cycle the knee and then retension. The hemostat is then placed underneath the soft tissues to facilitate passage underneath the soft tissues for the internal brace. We then use SwiveLock fixation to secure the internal brace in the fibular head. This also provides a tenodesis effect on the LCL graft at the fibula. In this case, we're using a 5.5mm SwiveLock anchor. The knee is placed in 30 degrees of flexion and the internal brace is then measured, making sure not to over tension the internal brace. We then mark it. Back it up and then dock it into the fibula. The internal brace is then cut and all sutures can then be removed. There is definitely variability in the lengths of the graphs. An alternative that I often use instead of placing the FiberTag on the LCL on the back table, I actually pass the graph up through the fibula to the soft tissue, and then cut the graph to a specified length to provide adequate tensioning of the graph. The alternative would be to potentially make the graph too long on the back table, and then you cannot fully tension the graph. So the alternative is to actually place the FiberTag TightRope on the LCL graph once it's in the patient. This concludes the posterolateral corner anatomic reconstruction using all TightRope fixation and internal brace augmentation. The normal rehab protocol for this reconstruction is. Range of motion is tolerated in a brace, and weight bearing is tolerated in extension. If there are other ligaments that are reconstructed, that's accounted for in the rehab protocol.

Michael G. Baraga, MD (Miami, FL), demonstrates a medial collateral ligament (MCL) reconstruction using a FiberTag® TightRope® implant and 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.

MCL Reconstruction With the FiberTag® TightRope® Implant and the InternalBrace™ Technique

Hi, this is Mike Baraga. And today we're going to be going over a technique for a superficial medial collateral ligament reconstruction using new FiberTag TightRope on both the femoral and the tibial sides with an internal brace backup as well. First thing we need to do is identify the proper landmarks for reconstruction. And in your thinner patients, you'll be able to easily identify first the adductor tendon and your adductor tubercle as the lighthouse of the medial aspect of the knee, which will essentially give you all other landmarks for you. Realize that distal and anterior to this you'll find the medial epicondyle, and proximal and posterior you will find the femoral attachment site of the superficial medial collateral ligament, approximately 6 to 7cm. Distal to the joint line, you'll find the distal tibial attachment of the superficial medial collateral ligament, which lies deep to the tendons. You also have a proximal soft tissue attachment spot between a centimeter and a centimeter and centimeter and a half distal to the joint line, where we will also be placing an anchor for fixation. So we've made our approaches both at the femoral side and on the tibial side. We'll focus first on the femoral side. So again after making the incision we've identified the medial epicondyle and identified the femoral insertion site of the superficial MCL being both proximal and posterior to this. And at this spot, we will begin with our spade tip guide pin aiming across slightly proximal and anterior, especially in the setting of an ACL reconstruction. To avoid the femoral socket, we'll ream our socket to approximately 30 to 40mm in depth. So now looking at our tibial incision, we've dissected the pest tendons and reflected them to show the tibial insertion site, the distal one of the superficial medial collateral ligament. As you can see it on the posterior medial aspect of the tibia. And this is a spot, as we had measured out approximately six centimeters distal to the tibial joint line. So at this spot we'll aim with our spade tip guide pin right on that posteromedial edge, making sure to aim from that posterior medial edge. Aiming anterolateral. And now we will be reaming our socket for our distal tibial insertion. This one will generally bottom out either way between 25 and 30mm. So I generally when placing the graft I'd like to deploy this TightRope first. And once I get this graft into the tibial socket then finishing the femoral socket deployment, we'll demonstrate that now. So here we have our graft. Typically we used either an anterior or a posterior tibialis tendon or peroneus longus allograft for the reconstruction. Here we have it built on two FiberTag TightRope. Whichever side you choose for the femoral side, I do lengthen that TightRope and ensure we can get the button completely across the femur and on the femoral TightRope, we've placed a FiberTape suture for our internal brace that will be fixed distally, just proximal to the distal superficial MCL fixation. For that, we will use the new ACL backup kit, which comes with your standard drill 4.75mm tap, but also a larger 5.2mm tap, especially useful for harder bone in this region. So we'll start by drilling the position of our SwiveLock anchor in the tibia, which is proximal to the distal insertion site. And we'll use our new 5.2mm tap, especially for the hard bone that's located in this area. And normally I'd use like Electrocautery really mark it out. And right now we'll leave this in to mark our site as we get our graft ready for passage. Now we will take our femoral sutures. We'll shuttle our femoral sutures, making sure to leave our internal brace tape down distally. [00:04:25] There you go. All right. Now, we'll take the sutures through to the femoral side. Now we'll take off the. So once that's deployed on the opposite side, you can take a curved hemostat or a clamp to really test that out and pull it back. Or you can pull distally as well. And that's solidly fixed in there. So because we have less room on the tibial side than we do on the femoral side, when we do do the cinching, I do like to cinch the tibial side in first. As you have less risk of bottoming out on the femoral side. Okay. But first what we will do is we will fix the internal brace prior to cinching the graft down, as this is going to end up deep to our tibial MCL graft. And for this we'll place the knee approximately 20 degrees of flexion. And you'll also apply a varus force. We can begin to cinch our tibial TightRope. And again it's not the graft itself is not fixed on the femur. This could be done at any angle. But we'll get this into the socket. So that's in the socket on the tibial side. And again we'll have plenty of length if you use a 16 centimeter in length graft to get this onto the femoral side. So now we ensure getting the knee back up to 30. So the graft is deployed in there. Again you can see your superficial MCL graft coming in your internal brace just deep to that. And again you can see your superficial MCL coming down into the socket on the tibia, your internal brace just posterior to it, the graft going in deep to layer one and into the femoral socket proximal and posterior to the medial epicondyle. Using suspensory fixation on both sides, final fixation will be an anchor placed about a centimeter to a centimeter and a half distal to the joint line. For these, I find the 1.6mm FiberTak anchors to be a great option as well. But there are many different suture anchor options that can be used. And you can see the distal tibial insertion site. How have you preserved some of this insertion? You can split this longitudinally. And the graft comes in right at the anatomic site. And you could reinforce this also with number two FiberWire suture suturing your graft to the native tibial insertion site as well. So for the proximal soft tissue fixation there's numerous anchor options that can be used. In this case we've used a knotless Corkscrew anchor that we've wrapped around our graft and will now be cinching it in for that proximal fixation point just distal to the joint line. And again, we want to bring the knee out to 30 degrees of flexion just prior to fixation. And I place the anchor just anterior. Since the knee was in flexion as an extension this will sit just posterior to it. And there's that final fixation point.

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

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

Scott T. Watson, MD (Greenville, SC), presents repair techniques for medial collateral ligament (MCL) tears and reviews biomechanical data.

Advancements in the Treatment of Medial-Sided Knee Ligament Injuries

I'm Scott Watson from Greenville, South Carolina. I appreciate the opportunity to do this and for Arthrex for hosting this meeting. It's been great so far. So I'm going to talk about medial side of knee ligament injuries, mostly MCL tears. Historically I think we were all taught to non-op MCL tears. I know in residency Rich Hawkins used to tell us never fix an MCL. They'll just get stiff or get infected. And there's been some data to report to support that over the years, with the exception of posteromedial corner injuries or the center type lesion distally, Shelborne and other authors have reported long term outcomes showing equivocal outcomes with non-operative management. I think the challenge in this is determining what's successful non-operative management in these athletes, and then we have biomechanical data to show us that maybe that's not the case, that it does seem our ACL grafts see more stress if we leave the medial side lax. And then you've got knee dislocations, which is a whole nother class of injuries. And I think it's important to understand that in some cases this is a complex multiplanar instability. It's not just valgus, a little bit of laxity at 20 degrees. So how do we diagnose these. There's a variety of exam tools which are not worth our time to discuss with this audience. But Cohen, Vortex and Doctor Laprad did a nice study showing us that with stress, fluoroscopy of valgus as little as 3.2mm of gapping compared to the contralateral side can be indicative of a grade three MCL or a complete superficial MCL tear. I use this very often in the operating room. You can use it in the clinic as well, but I've had difficulty getting patients when they're painful to relax enough, so we're stuck with the decision making process of when we have an ACL and an MCL. Initially, nonoperative management versus acute repair or reconstruction, or a posteromedial corner reconstruction. In addition to that standard, as well as Doctor Levy's groups have shown us over the years that with knee dislocation populations, the repairs are inferior to a reconstruction. And then we start talking about the InternalBrace frontier, which Arthrex and Doctor McKay have pioneered and really transformed the way we treat ligament injuries. I'm not going to directly go over his technique today, but I think you're all familiar with it from a repair standpoint. I think this has use and maybe changes the paradigm of why would we not non-op all these people and let them get stiff for several weeks when we could just repair and start the rehab and recovery? This has been described by multiple authors, including Doctor De Felice, who was up here earlier, as well as validated biomechanically for posterior medial corner repairs, with internal brace augmentation showing that it's similar to a reconstruction and better than repair alone. So I'm going to demonstrate our technique, which we use with dual TightRope suspensory fixation for MCL fixation, similar to what Armondo just showed on the lateral side. I'd like to use an allograft Achilles or tibialis anterior. We published this technique in arthroscopy techniques. So you can do this really minimally invasively with two small incisions on the femoral side. I like to use fluoroscopy to identify the isometric point, which has been described by standards group to be very predictable. You aim your four zero spade tip pin proximally and anteriorly and ream your socket of the appropriate tenodesis reamer and then shuttle your sutures across. Then you can go down to the tibial side using the pezze tendons as your landmark, and you usually have some native MCL there distally, unless it's a distal avulsion. And then you can use the six centimeter landmark distal to the joint line that's been described as well. So we tunnel underneath the tendons there. After we get that this is a four spade tip pin. And you got to be careful to aim this anteriorly as you go out the lateral side, obviously to avoid the peroneal nerve. That's a concern of people. I've done this in about 50 patients, and we're in the process of writing up their follow up. But we've never seen a neurovascular injury. So another key point is putting a stitch in the trail end of that TightRope, either using the RTA or adding your own stitch back there. And that helps flipping at that stage right there, which also limits your risk of the button walking off the bone or having nerve vascular injury. So dock it in the femoral side. This graph usually is 110mm, about 100 110 extra osseous. So I'll cut it to 150 or 160. You have more room on the femoral side to dock your graph so that tunnel gets longer. And I go ahead and dock 20 to 30 on that side before I shuttle down to the to the tibial side, underneath the tendons, and then dock your graft on the tibial side as well. And again, I think this I call it a flipping stitch, but it's the trail end stitch really helps you with this step right here. And then you pull that trail in stitch and it'll flip it flush with the cortex, keeping some back tension to make sure your button doesn't walk off the bone. And then there's our final x ray there. So the posterior medial corner, which we've learned a lot more about in recent years, the five main structures there with the Semimembranosus and its expansion kind of in the hallmark, there really a much more severe MCL injury and Anteromedial Rotatory instability and just a different animal than just your simple MCL. So in that case, we've described our TightRope fixation and reconstruction for the Pol as well as the MCL. We'll use an Achilles graft that's split with TightRope on both ends or all three ends. So here we're dissecting out. That's the Semimembranosus, which is your landmark. So we'll dissect that out, pass the suture behind it. And then the remainder of the technique is fairly similar to what I just showed. So you identify your isometric point. Create a socket on the femoral side. And then coming distally. Pets. Tendons are your landmark. Go distal to those you have some native MCL distally. Create a similar socket to what I just showed. This graph has to be bigger and you have to have two ends. I've done this with an Achilles as opposed to two separate tunnels on the femoral side. We've made a basically I call it a bifid Achilles graph. Then here we're identifying our posterior oblique ligament, which will be proximal and posterior to the distal MCL just below the joint line. You can do this with TightRope and the multi ligamentous knee setting. I'll do it with just an interference screw to not have tunnel convergence with PCL tunnels or others. There's an example of our graph using the graph tubes which I highly recommend. And these are FiberTag TightRope. So we'll dock it similar to the previous technique up into the femoral side. Usually go 20 to 30 initially and then shuttle your grafts down for your MCL. This one's got an internal brace here, which is my technique. Preferred that I do every time now. The nice thing about that is you can help pull it on the femoral TightRope to keep it flush with the cortex as well as you tension these. And then now we're shuttling the pol around the semimembranosus and then through the posterior medial corner tunnel. The pol tunnel will tension the pol and extension after we've already applied some tension to the femoral side. So you tension that TightRope you see it tightening up right there. Then we can cycle the knee. This is really the advantage of TightRope collateral fixation in my hands. You can dial in your tension cycle the knee stress it and valgus and tension those independently similar to what Armando showed laterally. So these are the advantages I discuss. You also get cortical fixation. You're not worried about interference screws, especially in the femoral side where the bone can be poor and you can adjust your tension easily, augment with an internal brace, and it can be as minimally invasive as you need it to be based on based on your pathology. So we wanted to study this with the support of Arthrex and Cohen Vortex and John Koditschek and their team. We studied this in the lab with three groups, comparing just the traditional interference screws, the double TightRope technique, and then the double TightRope with internal brace. We stressed it at time zero cycled it, and recorded stiffness, displacement, as well as ultimate load to failure data, and the internal brace double TightRope group was superior in all three categories. The interference screws were very poor as far as the fixation was performed, and all the double TightRope without an internal brace was also superior to the interference screw, as well as very similar to the native MCL data. So some conclusions for that double suspensory fixation with or without internal brace is mechanically superior to the interference screws, which we've used traditionally, and double suspensory with internal brace is the most mechanically similar to the native MCL. Thank you.

Armando F. Vidal, MD (Vail, CO), presents innovations in posterolateral corner reconstructions.

Fibular-Based Technique for Posterolateral Corner Reconstructions

All right. Let's talk about the lateral side of the knee. So the lateral side has always been called the dark side of the knee. And I think a lot of it has to do with that. We lacked an understanding of the anatomy, the biomechanics and appropriate reconstructive techniques. So parallels to what we just talked about on the medial side. So this is something that's near and dear to my heart. This is a technique that I've been doing for the past probably 6 or 7 years with some modifications. Now with FiberTag TightRope. My goal here is to simplify this for you guys. I would highly encourage that either today or tomorrow in the lab, you spend a little bit of time doing this because if you're called upon to do lateral reconstruction, I think a lot of people have fear about the nerve about how to reconstruct it. And this is a simple technique, and this is a modification of our cross technique, so that the most common techniques that are used for the lateral side are either our cross technique, which is what this is a figure of eight or Doctor Laprade's technique one is more challenging than the other, and I'll talk about how I make a distinction. I do both techniques, how I make a distinction about which technique I'm going to use, and this technique serves me well about 70% of the time. So, as you guys know, the FCL or the LCL is the primary stabilizer of the knee. It has a secondary role in controlling rotation, but the lateral side, similar to what we just discussed in the medial side is a complex right. And when I was a fellow and a resident, we talked about the arcuate complex and all these little ligaments that you couldn't see on MRI and you couldn't see with gross anatomy. And we really boiled it down to the FCL, the pulpitis and the ligaments. When we talk about lateral cited reconstructions, those are the three structures that we focus on. You can have lateral meniscus injuries and meniscal fascicle injuries, etc., but these are the three most important structures that we're going to talk about when we talk about doing lateral cited reconstructions. Now the problem with the lateral side is that people are fearful because they're not comfortable with that anatomy. The diagnosis can be challenging. I would argue that MRI isn't reliable. You'll see a case like this where there's a lot of edema in the posterolateral plateau, but the lateral side is intact. And then you have a case like this where the lateral side is pretty quiet. But you can clearly see that the FCL is pulled. And actually in this case the biceps as well is pulled off the fibular head. The other challenge with MRI is that it's not very reliable in the chronic setting. I'm going to show you an example of that. Our physical exam is helpful, but I will argue that I have been fooled, and I do a lot of a lot of knee dislocations and a lot of collateral ligament surgery. And I've convinced myself, based on their mechanism or their story, that it's a lateral sided injury. And all I'm doing is reducing their high grade medial sided injury or vice versa. So if you think there's a collateral ligament, especially in a revision situation or a chronic situation, I always use stress radiography to confirm what I think is going on clinically. It helps me to quantify the extent of the injury, but it also helps me to confirm what I'm seeing because I've been fooled. I had a guy that had a previous ACL and he had a medial tibial plateau, and I thought for sure he was grossly unstable. His ACL was out, grossly unstable. Varus valgus stress. I thought for sure his lateral sides out because that makes sense. He had a varus load. He fractured his medial plateau. But what really happened is when they plated his medial tibial plateau, they took out the MCL and all the medial sided structures. But on clinical exam, I had convinced myself that the ESI with the mind knows, convinced myself it was a was a lateral sided injury. It was only with stress radiography that I was able to determine that it was the medial side, and we actually removed his plate and reconstructed the medial side. So stress radiography, I would argue, is very key if you're going to be doing any collateral ligament surgery. The reason MRI isn't reliable is because by MRI these lesions can heal. So if you're looking at a revision ACL, if you're looking at a guy or a gal who's 2 or 3 months out from their injury, that MRI can look totally normal. So this is a wrestler. He had another opponent fall on him. He had a huge varus load to his knee. He was from Wyoming. You can see he had an acute MRI. You can see there's clearly significant injury in the lateral side. There's a stretch to the FCL. The posterolateral corner is out. It was isolated so they treated it non-operatively which I don't think was necessarily the bad call. But he continued to have instability. So they remarried him in February. And that MRI looks totally normal, right. And this kid was still unstable and ultimately required a reconstruction despite having a relatively normal appearing MRI. So I would challenge you that if you see a normal MRI, don't be fooled to think that that lateral side is side is necessarily intact, and the same goes for the medial side. You need to rely on your clinical judgment, your exam, and ultimately confirmatory stress radiography if you feel it's appropriate. Low grade. I think there's really no debate, right. I think that most of these injuries can heal or really aren't clinically significant. We all know that grade three complete injuries result in persistent instability, degenerative change, and obviously have suboptimal outcomes with cruciate ligament injury. Now where the controversy really arises is what's the best management? And I would say historically repair has generally been considered to be inferior. So everybody quotes standards paper and Bruce Lee's paper. And I think there's still something to be said about that. And if you look at standards paper, the repairs did worse than the reconstructions, but the repairs that took did better than the reconstructions, and a lot of the repairs that fail were done chronically. So if you're going to repair them, you have to get to them acutely. So I still think there's a role for repair. And the other thing that I would say about repair is that these were all done before the era of everything you've heard about today, which is suture augmentation, internal bracing, which I really think is shifting the paradigm for the role of primary repair in these acute settings. We talked about it with the medial side. We've seen it with ACL. So I think this slide is going to continue to evolve and change. But reconstruction still remains the gold standard. And that can either be fibula based which is our technique or fibula and tibia based. I'm going to show you the distinction at the end of this talk, which is the Lapradd reconstruction in my hands. If I can repair it, I'm going to repair it, but I'm always going to augment it, typically with an allograft similar to what Greg was presenting with in his ACL algorithm. But I like to put collagen in there. But I'm getting more aggressive with primary repair, with SutureTape augmentation, if the tissue is good and I really feel I can get a good quality repair. So the focus of this talk, though, is I'm going to take you through the surgical reconstruction here, live here in a little bit, but I do this again. It's an Arrow technique. I do it with an all soft tissue allograft. You can use a semi or peroneus and anterior tib, but ideally you want to get to about a seven millimeter diameter graft. The reason that's important is because anything bigger than the fibular head, maybe a seven and a half, is challenging. And one of the biggest complications you can have from this is fracturing the fibular head. It's one of the few complications that are really difficult to bounce back from. The graft in my hands is 25 or 26cm in length. And when we do this live, I'll show you why we get to those numbers. And I do augment all my collaterals. Actually, at this point, I augment almost all my surgeries with an internal brace. I do pcls with internal brace collaterals. Probably the only operation I still don't internally. Brace is a BTB autograft ACL, but after Lee's talk maybe I should consider it as well. But we'll use two FiberTag TightRope and we'll do an internal brace for the FCL with a SwiveLock anchor on the fibular head. So the approach I think is pretty well established. So it's a typical laterally based approach posterior flap. When we do this live I'm going to take you through the windows. But you need to find the nerve. If you're going to be working around the fibular head you need to know where that nerve is. You got to feel comfortable dissecting it. It actually is a lot easier than you think. So we'll make a small nick in the in the and the biceps femoris in line with its FiberStitch will allow you to have exposure to the fibular collateral ligament, and you'll tag it, which allows you to put it on tension and identify its insertion on the on the femur. We'll talk about it in the live session, but there are three windows we work through. And this window, which is the window through the IT band, is what's going to allow you exposure to the femoral insertion of the FCL and Popliteus. So we're going to find the FCL again. You can keep it on tension with that stitch. We'll make a small vertical arthrotomy. That's the palpation and that's the FCL. And based on anatomic numbers that should be about 18mm apart. Insertion to insertion site. So once we do that you can use a guide to do the fibular tunnel. I actually freehand it most of the time. But if you don't have a strong comfort level I think a guide is reasonable and can serve as your retractor in the back. This guide is similar to the PCL guide, is really good at capturing that pin and protecting your neurovascular structures. The fibular head tunnel should be about an inch long. It's about 2420 five millimeters in length, so that gives you a good idea When you put this guy down, that you're in the right level in the fibular head. So you need to be in the thick part of the fibular head. I always check Flora when I put that pin in, and probably about 30% of the time I move it because I think so. What I'll do is I'll get Flora with an AP, and then I'll get a Flora straight down where that pin is, to make sure that I'm at the right height in the fibular head. And then when I ream it, then I'm not going to blow out the lateral cortex, blow out that lateral cortex. It's really limited in terms of your options. You have to fix it with suture anchors, tensioning is difficult, etc.. In terms of our femoral tunnels, this is really not that different from what we do with a lot of other ligament reconstructions. We're going to drill two sockets. I'm going to show you when we do this live here in a second is I drill the femoral side on the FCL really deep because if your graft is too long. So the questions I get asked about this the most, because we have this on the Arthrex website, is how long do you make the graft and what do you do if the graft is too long? A graph that's too long is easy to manage. A graph that's too short is impossible to bounce back from. You got to start over. So 25cm works well. You drill it on the on the femoral side, but you over drill it. As long as if you're going to intersect your ACL tunnel, you're going to do that at the beginning. You're not going to do that 50mm in. So you can drill that pretty far. You're going to aim this a little bit anterior and medial and you can. And that way you can dock the graft in further. If you end up with a graft that's that's too long in terms of passing it. Again we have a all soft tissue graft. Two FiberTag TightRope. The reason I like to have two FiberTag TightRope is it allows me to independently tension the Popliteus and the FCL graft. So we're going to pass it through. There is a InternalBrace of FiberTape that is passed into that button. It gets deployed. It gets docked in. Believe it or not, if you get facile with this operation, you can get to a point where you can do this in about 20 minutes, maybe 25, depending on the anatomy, etc. but you dock it in, you go deep to the IT band. I remember early in my practice being all psyched. I did my first one of these. It was great. And then I realized I passed it superficial to the IT band and had to start all over. So over. So you just need to be methodical with what you do. So you pass it deep to the IT band along the course of the FCL. It then goes front to back through the fibular head. The IT band. Sorry, the internal brace stays out. You just pass the button and the graft. Mineral oil can be helpful in this context too, just to lube the graft to pass it through. This is oftentimes the hardest part, as you can see here. We'll see if it's smooth when we do it. Live in that cadaver. And then you pass it on the palpation so deep to the FCL along the popliteus sheath, which you can easily find with a Kelly, and you create that figure of eight. In terms of tensioning. Once you pass it, the tension is loose on the grass. As you can see. You can cycle it. You can do your cruciate. We're going to fix it on the fibular head with a with a SwiveLock as our interference screw. Right. So we're going to fix this in 30 degrees of flexion neutral rotation with a valgus load applied to close down the lateral side you're going to load the internal brace. Race. And even though you don't have to sit the tension on the FCL at this point, you are setting the tension on your internal brace. As you can see there. So you're going to fixate it. We still have our FiberTag TightRope on each of the two graphs, which are now independent because they've been fixed on the fibula. And you can independently tension those two graphs after the fact, which I think is really the elegance of this particular procedure. I like this technique because it's simple. It simplifies a very difficult operation. For most. It's biomechanically strong. It allows for rapid graph preparation. It's reproducible. It's tenable at various points. It's bone preserving. So if you think of the classic way we did it, we'd do a split Achilles with a nine millimeters bone block and a screw, and you've got an ACL. You now have three holes in the femoral condyle that are huge. So this is a seven millimeter hole which is pretty small. And if you do an R0 it avoids posterior tibial dissection. And I would argue there's ample biomechanical data and clinical data that would suggest that there is no huge difference between a Lapradd and an R0. I said earlier when do I use a laptop? And so this picture on the right is a laptop. So if you look at it, there are two distinctions. So you have the tibial the common tibial tunnel on a leopard. Right. So what happens with a leopard is that the popliteus graft goes to the tibia instead of the back of the fibular head. So there's a little distinction in where that graft inserts. But additionally you have the part of the graft from the FCL that goes from the back of the fibula to the tibia. That little part, that little pop fib reconstruction is also, incidentally, how we do tib fib reconstructions. So the context that I will do a lapradd is if they have asymmetric hyperextension on exam. And that's something that Bruce Levy taught me, that they need that posterior sling from the femur to the tibia to help is almost like a trampoline to take out that hyperextension. Or if they have tib fib instability as noted on exam. So you have a case like this where you open it up and that fibula is grossly loose. You cannot have a fibular base reconstruction in isolation. Now the guys in New Mexico published a paper showing that they both fail if the tib fib joint is loose. But we know there's a significant percentage of these multi-leg knee injuries that have tib fib instability. I would argue that their paper was flawed because they popped the tib fib joint after the reconstruction. So in summary, I think in our technique can be utilized in the majority of lateral reconstructions. I will use a little prod if they have asymmetric hyperextension or tib fib instability. The challenge of the lapradd is that nobody likes to do that. Poster dissection in the tibia. It is dicey. It's close to the neurovascular structures. And this is a case that was referred to me. She was done by a well experienced multi ligament surgeon. And that screw is right through the tib fib joint. If you look at it on the AP in the lateral. And she couldn't explain why she had Lansing pain down her tibia. And so we actually ultimately had to revise this case. We first took out the screw. She had symptom relief for a couple days and then ultimately revised it. So we'll we'll go through this live here in a second and I'll entertain questions. But but thanks for your time.

Anatomic Collateral Ligament Reconstruction

Child (D)

Multiple collateral ligament reconstruction techniques, from aperture fixation using the BioComposite SwiveLock® tenodesis system with biocomposite interference screws to suspensory fixation using TightRope® technology, are available.
FiberTak® soft anchors and biocomposite suture anchors, which come preloaded with needles, are part of a comprehensive line of anchor fixation devices supporting primary or hybrid collateral ligament repair and reconstruction techniques.

Collateral Ligament Reconstruction

Anatomic Collateral Ligament Reconstruction

Collateral Ligament Graft Fixation