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FiberRing suture allows for simplified and reproducible suture passing and implant loading.&nbsp;
 
 
Multiple lengths—including 25 mm, 35 mm, 45 mm, and 55 mm—allow surgeons to create points of soft-tissue fixation at different points in the remnant tissue while balancing the tensioning. For example, a longer FiberRing suture can be used to place an initial luggage tag pass and a second or even third additional pass through the tissue while enough length remains to connect to the TightRope® implant.&nbsp;
 
 
Additionally, longer FiberRing sutures are popular in spine avulsion cases that use longer tunnels through the tibia.

Wiemi A. Douoguih, MD (Washington, DC), demonstrates a new technique for tibial spine avulsion repair using FiberRing™ sutures and the ACL Repair TightRope® implant.
 
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.

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video

Tibial Spine Avulsion Repair Using the ACL Repair TightRope® Implant With FiberRing™ Sutures

Hi, I'm Doctor William DualWave, regional medical director for MedStar Sports Medicine, MedStar Health in Washington, DC. Today, I'm going to be talking to you about my technique for tibial spine avulsion fracture with internal brace. On top you're going to see the FlipCutter three for the tibial tunnel. Below that is the FiberSnare in black. Then you see the TightRope pin for femoral internal brace, followed by the FiberSnare in blue and white. You'll then see two fiber rings for ligament repair. And then you have the FiberTape loaded on a TightRope button for the internal brace technique. Then you have the repair TightRope. Finally, there's a SwiveLock to fixate the internal brace on the tibia. So here we have a tibial spine avulsion fracture. If you look you can see the bony component underneath. And here's this distal tibial insertion of the ACL disruption. So we're going to fix this today using a FiberRing technique and an internal brace. If you look up here you can trace this approximately. You see that the femoral origin is intact. Femoral origin of the ACL is intact up here. And then we have an isolated distal avulsion. So here I typically use a two passport. We're going to insert this into the joint. So the first thing that we're going to do today is we're going to going to drill our tibial tunnel through the tibial tunnel. We're going to pass our repair sutures, but we're also going to pass our internal brace. So we're going to try to get in here right in the base of our tibial tunnel. So here we're drilling right in the anterior margin of the tibial footprint of the ACL. We're going to pass our FlipCutter. We don't deploy it. So we're going to pass our black FiberSnare in through our tunnel that we just drilled. And this is going to be used to pass not only our repair sutures but our internal brace all through the same tunnel. Okay. So now we're delivering the FiberSnare. So now we have our passing suture, and we'll dock that here outside the Anteromedial portal. So now what we're going to do is we're going to turn our attention to the femoral side and get ready to pass it to our internal brace. So now we're going to take our TightRope pin in preparation for creating passage for our internal brace. And we're going to go right through the femoral footprint. Okay. So now we're going to pull our blue white FiberSnare into the femoral tunnel. And then we're just going to dock our suture here. And then we're going to proceed to repair the tibial spine avulsion. So we're going to take our FiberRing sutures first. So first I'm going to pass my suture here. It's our first fiber ring. And we're going to load up our second fiber ring and pass it on the lateral side of the ligament. Okay. Here it's going to be our second suture a little more proximally a little more laterally. Okay. And we'll pull that snug. There we go. So we're going to pass the more medial distal suture first. So I'm going to dock this outside my accessory anteromedial portal. We'll pull this out first here. And that will allow us to work on the medial suture without having to worry about suture management issues. So now we've cut the suture so that we can bring our repair TightRope in. So we're going to bring our repair TightRope up. Here's our repair TightRope. So we're going to start with number one. And if you notice here this is sort of our passing suture. This is what's going to ultimately become the TightRope two. So we're going to pass this through the loop. And then I'm gonna have my assistant pull that through. And this is going to load our first fiber ring. So now we're going to retrieve the second suture. So if you see here this, this suture is all in one. And we're actually going to cut this just distal this convergent point. So now I'm going to pass this through again and then use the other side of our FiberRing passage device to bring it into the knee. And there we are. So now we've passed it through both. And I'm going to continue to pull this through until I am completely loaded the loop from my TightRope. So now we're going to cut this black and white suture. And we're going to discard that. So then you always want to make sure that that you're not tangled as you as you go in. So we're going to take this, our KingFisher and slide it down through the passport just to make sure we're not tangled, which we're not. And now we can proceed to the next step. Cut this black and white because that's just our passing suture. We'll discard that. Now I'm going to free up the second part of this suture. So we're going to take this tail. And the tail is going to go through the loop that's docked outside of our passport cannula. So once we've passed that through there, we're going to pass it through the wire loop in the card. And I'm going to have my after I kind of hold it, pinch it and have my assistant pull that through. And sometimes you got to pull firmly. There it goes. And now you've loaded your TightRope two. So if you look on the back, we're going to release this and loosen everything up. And then we open up the card and we just pull it through. So you have plenty of length. We don't need all this length. And we're going to shorten it down just for ease of passage and to prevent getting tangled in the in the knee joint. Looking inside the joint here, you can see we've got our two FiberRing sutures and we're ready to go. So now we're going to create an internal brace with cortical femoral fixation. And so I'm going to get my passing suture I'm going to come up here and I'm going to grab our passing suture. This is our blue white FiberSnare that we placed in here earlier. We're going to bring it out through the passport. All right. Now I'm going to have my assistant pass the two tails of our number five FiberWire suture that's embedded in our button through the FiberSnare. And we're going to draw this into the socket. We're going to carefully draw our button in through the tunnel that we drilled earlier. We're going to pull it out until it locks on the femoral cortex. Let's pull it back and see if we've locked it. So our button is locked on the femoral cortex now. And that's going to serve as our as our internal brace. So we've got our repair sutures, we've got our two fiber rings, and we have our FiberTape that's going to serve as an internal brace. And now we're going to draw this all through our tibial tunnel. So now we're going to take the internal brace off of our repair TightRope. We don't need this here in this setting. If we're doing an ACL repair on the opposite side on the femoral side, that this would serve as our internal brace. But we have to create a separate internal brace here. And so now we're going to draw all of this through. And you just want to make sure you're not tangled. Let's take our KingFisher. Again this is really critical. You really want to make sure each step of the way that you're not tangled. Because if you get tangled, it's going to be very difficult to kind of get your way out of it. And with that simple step, you can make this into a very simple procedure. Okay. So now we're going to going to draw this all down into the tunnel that we had drilled on the tibial side. There's the button. So now we're coming in. Now my button's out. The internal brace I can actually pull separately. There's the internal brace. So now we just pull this down. So here are my repair sutures tensioning down the distal stump of the ACL. And here's my internal brace. Once we've got that all set up we're going to use the winch mechanism on our TightRope. And we're going to secure our repair. That's the first step. Yep. So I'm going to hold the button as we tension this down to the tibia. So now we're going to do is we're going to tension down our repair suture I like to bring it up to within 20 degrees of extension. And now we're going to bring this button down to the anteromedial tibial cortex. Sort of guiding it right down onto the anterior tibial cortex to make sure our soft tissues are freed from around the button. And then we'll continue to tighten it down so you can tighten it a little bit more. And the nice thing about this technique is you can always retension it. That's perfect. So now that we've had we have that down, now we're going to work on our internal brace. And then we'll replace that with the tap. Perfect. So now we're going to pass our internal brace sutures into the 4.75mm SwiveLock. And you don't want this to be too tight. So what I'll actually do is as we pull this back out, I'll have a little bit of slack built into this. So I kind of go past where my hole is going to be. Find our hole. I'm going to unclean our number two FiberWire suture. And so you can load this. Make sure you're in there about 10 pounds of pressure. It's not going anywhere. We know we're well seated. So before we're done I always like to do my Lachman. Take it through a range of motion. And if for some reason it's not tight enough. The beauty of this is that you can retension your repair sutures. So after you're done, if for some reason you feel like you need to retension it, you can. We'll go take a look inside the knee. So you look here. Here's our internal brace. Nice tension. The internal brace. Real nice tension in our ACL. We've restored our tension. It's well secured. If you're concerned about it, you can tension it some more. We're secure on one side, we're secure on another. We've restored nice tension in the ACL. We haven't over tightened this. I can kind of fit my probe underneath which is good. And I'm very pleased with that construct. So post-operatively I don't treat these any any differently than I would an ACL reconstruction. In general, these tend to move faster because you haven't harvested a graft from somewhere else in the knee. You've preserved proprioception because you've kept the native ACL, so they tend to meet their milestones faster. But the protocol is the same. I found in general that these patients tend to get back a little bit earlier to their activities from a functional standpoint, but this is just a nice technique that you can add to your armamentarium.

Sommer Hammoud, MD (Philadelphia, PA), demonstrates an arthroscopic double-bundle ACL repair using FiberTape® suture for the InternalBrace™ technique, dual ACL Repair TightRope® implants, and FiberRing™ sutures.
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.

Double-Bundle ACL Primary Repair Using Dual ACL Repair TightRope® Implants and FiberRing™ Sutures

So this is a left knee here. I like to make my initial portal high and tight, so I like to hug the tendon. And in normal patellar tendon length patients. So not patella baja or patella Alta relatively parallel to the inferior pole of the patella for the medial portal, because we'll be using an inside out or a FlipCutter technique. I like to view from here this being close to the patellar tendon is also important. To be able to bring the FlipCutter in safely and not touch the lateral femoral condyle articular cartilage. So you can see there are still some fibrous attachments at the very posterior aspect of the notch here. And that I believe is really common when I see Sherman type one tears. There's usually some fibrous attachment still intact, which is really nice because it allows you to identify anatomically, very easily your footprint. You can also see this tissue is kind of a nice congealed stump, so to speak. So this one works really well with the 25 millimeter fiber rings in some patients. You see that this tissue is a little bit more striated. Rioted. In those. There is a longer FiberRing option where you can start closer to the base of the tissue and make multiple throws so that the FiberRing doesn't pull through the tissue. But it's nice when you have a congealed kind of solid stump of tissue like you see here, because it works very nicely with the ACL repair, and the FiberRing holds really nicely in the tissue. So sometimes I will do a limited notch plasty of the very anterior notch, particularly when you have more of the reverse shaped notches where it's more narrow and it widens as you go towards the back. This one is more of a typical notch, and you have a direct view to the femoral attachment of the ACL. I would encourage you to perform a limited notch plasty to the anterior notch, as well as keep this lateral portal tight to the tendon so that you can see around the corner and have good visualization of the anatomic attachment. I don't like to extend that notch plasty back into the femoral attachment of the ACL. I don't want to create a bigger gap for the repair. So I like to use the PowerPick to prepare the wall. Obviously we want good biology for healing. And so this PowerPick is really nice. It won't get the tissue wrapped up into it, and it allows you to put small drill holes in essentially microfracture, the attachment site, to improve the healing response. I like this better than using the bur or bone cutter on the femoral attachment, because I worry about removing bone and creating more gap between the repair tissue and the anatomic attachment. This is the FlipCutter guide that we're going to use for our PL bundle. So what you need to do in order to avoid the condyle is you need to bring this in and actually angle your arm this way. So in order to bring this in safely and not go directly into the condyle and potentially injure the cartilage. I like to place it in like this. And so it needs to be totally closed. And sometimes with that drill sleeve in there, it will get in the way. And so what we'll do here is we'll come in and if you see arthroscopically how I How I can angle it and get it around the condyle, and then start to move my way back to the femoral attachment. Once I have it in, as you can see here, with us being able to directly visualize, we can place it where we'd like it. And once I have those sharp flutes locked into the femur, I'm toeing in, as you see externally here. See how this thumb is really pressing in to toe in? And even if I switch hands as I'm right handed, you'll see that I continue to maintain this toe in. And so now I'll loosen it. I'll adjust it to the position that I usually like. For me that's typically 110. And then I'll place the drill sleeve through and onto the lateral femur. And so what I'll do is I'll typically just make a mark onto the skin laterally here I'll come in with my 11 blade always directed more distally through the skin subcutaneous tissues and it band. This will go down onto the onto the lateral femoral cortex. You see here I have this insert here which is the guide for the two four pin. And I like to use the two four pin first one because it's a little bit more accurate than going straight to the FlipCutter, but also two because it leaves a much smaller pin hole. If I don't like where I am, I can always change it. The other thing with doing two tight ropes for this ACL repair, sometimes I like to be a little bit wider than the anatomic footprint, so it's getting more of a compression of the tissue like a parachute onto the bony footprint. So we'll come in here. If we like our spot we'll take the two four pin out. We'll mallet this in to maintain our lateral cortex for our suspensory fixation using the TightRope button I'll use this to remove the pin. I actually like to keep the guide in place. I use the FlipCutter when I'm doing my ACLs and keeping the guide in place until your FlipCutter is in, keeps the construct more rigid, and you're less likely to wobble with the drill sleeve and change your position. This will typically follow the guide for the two four pin very nicely, and then at this point with this guide in, I'll undo the barrel. I'll unlock it. And similarly to placing this guide in, I'll come out around the condyle safely so that I don't injure the articular cartilage. So we're using the FiberSnare here for our passing suture. I like to drill and pass this first just to avoid any potential injury to the FiberRing, which is going to be our working suture. So you see, it has a loop at the end here. This red sheath will shuttle it in through our drill sleeve. So we're using the FiberSnare here for our passing suture. I'll usually grab it and place it there and then come back, because I want to park this suture out of the lateral portal. So it's out of our way. At this point, the red sheath and the drill sleeve can come off. So you'll see we have the loop here and the free end here. Better for suture management. And then we'll just place the free end through the loop, and we'll tension this out of our way. And then we can keep working in. That suture is totally out of our way. So for the second tunnel for the Am bundle attachment it's going to include our tape suture for the internal brace. And it can sometimes get stuck a little bit. So what you want to do is piston in and out with your FlipCutter just to slightly widen that to make it easier to pass the TightRope suture. So now you can see here we have our two attachment sites, one for our PL bundle. You can see the back wall is there and one for our Am bundle. These are our two fiber snares which we will use to pass the TightRope sutures once we pass them through the tissue. So for this, I'm going to use a passport. I like to use the passport because it allows us to have good suture management and avoid soft tissue bridges, which would be really disastrous, kind of passing this up and through or getting it caught in our TightRope you can see this is our passport. Inserter. All we do is shove it right through the portal, and all you want to do is shoot past it and it dislodges off the passport inserter and then remove the passport Inserter. Here is how we're going to load the FiberRing onto our Scorpion, which we'll use to pass the sutures. You'll see the fiber ring goes directly over the shaft and this gets loaded into the jaw. Hold these sutures back as I insert it through the passport. I'm going to place the Am bundle suture first. So as I'm placing this FiberRing, some of the big considerations are the tissue quality, because the way that this fails is the fiber ring pulls through the tissue. So you'll see here where it's placed there's a relatively healthy tissue stump right there. But that's the main consideration in placing these that you want to be careful about. So as you'll see as we pull this out, the fiber ring slides over the suture that's being pulled out with the Scorpion. And we'll continue to pass that through this ring here right in front of my left hand, my fingertips. And this is a closed loop. So at this time we're going to cut this loop right at this free suture. So now you have two free strands. This loop is what's going to shuttle the TightRope in and through the fiber ring. So this is the TightRope. It's all labeled. We'll take the TigerWire leader suture, which is number one in the package. We'll place it through the fiber FiberRing shuttle eyelet. Double it over. Take the opposite end and you'll see that this shuttles that TigerWire leader. Suture all the way through your fiber ring. At this point, you'll completely unravel the remainder of number one. So once it's unraveled, we do that basically just to allow us the slack to get the TightRope through that fiber ring. So we're going to pull on the free end of the TigerWire leader suture. And as you see now, it's going to shuttle the TightRope in and around that fiber ring. So now at this point, this loop gets cut and you're just dealing with your TightRope. So now this takes you back to the more typical TightRope. So you're going to take the number two leading suture unravel it. This is going to go through the loop of suture and then a couple of inches Through the wire. At this point, the remaining suture will come off. Then we'll flip the card over. These tabs will open. These pinch in, and this can all come off. So now in passing our suture, we'll separate our tape because this is going to be our internal brace. And keep it with the rest of the TightRope loop. The TightRope tensioning sutures and the blue passing suture will go up through our FiberSnare that we already placed. So for suture management, even through the passport, what you want to do is tension all of the sutures down and keep your retriever more superior to keep it out of the way. We'll go grab that FiberSnare for the Am. And now this passport has allowed us to have all our sutures that we that we need out of the same portal. And no soft tissue bridge. These sutures will get passed through the ring of the FiberSnare for the Am. Double it over like that. And we will watch this go up and out. A couple of tricks here. As you're pulling the button up and out, if you prefer not to pull the button out of the lateral incision, which I often do, you can place counter tension with your fingers in the loop of the TightRope, and then ultimately, as that goes up into the knee joint, you can counter tension through the tape sutures to get a more controlled flip of the button. So now we're going to take the tensioning sutures for the TightRope. And your assistant is placing tension on the tape sutures, which keeps the button reduced to the lateral femoral cortex. And what we're going to do here is we're going to do just our initial set of the FiberRing. So you see now we have our initial tensioning. So we're going to put our second fiber ring. And this is our tape or internal brace technique construct which we will do at the end. Going to take our second fiber ring construct, load it in the same fashion as we did previously. So here I'm going to tension it and place the suture construct here. We'll place it through the fiber ring shuttle eyelet. Double it over. Take the opposite end. This shuttles that TigerWire leader suture all the way through your fiber ring. At this point, you'll completely unravel the remainder of number one. So once it's unraveled, we do that basically just to allow us the slack to get the TightRope through that fiber ring. So now at this point, this loop gets cut and you're just dealing with your TightRope. So now this takes you back to the more typical TightRope. So you're going to take the number two leading suture Unravel it. This is going to go through the loop of suture and then a couple of inches through the wire. At this point the remaining suture will come off. Then we'll flip the card over. These tabs will open. These pinch in and this can all come off. So we're going to use this tibial guide which you'll see. It's nice. It has a little oval at the end. And at the center point or connecting point of those three black hash marks is where the pin will come through. As a lot of times the pin will want to trace up the fibers. And so that oval ring is nice because it allows compression of the tissue to get the pin to puncture through at the most anterior portion. So at this point we can take the guide off. And this is our Cannulated two four pin. So we will unscrew the tip here. And it takes the inner sheath out. This is the nitinol wire loop, which will get shuttled up through the Cannulated drill bit. So now we'll come in through our medial portal to retrieve the nitinol passing loop. Sometimes this pin can be taken out by hand at this point. If not, what you can do is pull the wire through so that you can reattach your drill onto the back, and then just drill it straight out. So in this scenario, you can either use another passport cannula or switch this passport cannula into the medial portal. You can also shuttle in on top of the nitinol wire. Now you're in the same soft tissue plane. And then you can go retrieve your tape sutures. And now you know you don't have a soft tissue bridge. So now our tape sutures are through the eyelet of the nitinol wire, and we pull tension on the free end coming out of the tibial incision. And that internal brace will lay directly over our ACL repair and give us a nice reinforcement biomechanically to allow the tissue to heal. So at this point we're going to secure the internal brace, tape sutures onto the tibia. I typically get this prepared by passing the sutures through the SwiveLock anchor. I prefer to use a peak anchor. Tibial bone is typically quite dense, so this is the strongest really to avoid breakage as you're inserting it. So now to fix the 475 SwiveLock, we're going to use all the instruments that come into the ACL repair backup kit. So this is the initial drill. You'll drill down through the second step that it has. I will typically tap at least once in the tibia again because the bone is quite dense and the cortex can make placing an anchor difficult. If the bone is really hard, I will tap a second time. This is A52 tap. So at this point, once the anchor is down, we will go ahead and tension each of the tape sutures against the anchor. This will always be done in full extension so as not to capture the knee. Once you have the anchor completely down, you'll unravel your sutures and the inserter comes straight off. We'll unload this eyelet suture. So this is our final construct here. And what we can do, even after the internal brace is tensioned, is we can cycle the knee and do our final tensioning on our TightRope sutures. You can see there's really nice tension here. We have a nice wide, broad based anatomic reattachment to the femoral footprint. Nice tension on the tissue. So the final retention with your TightRope sutures can always be done at 90 degrees of flexion, but the internal brace construct needs to be done at terminal extension. So you can see here we can take the knee through range of motion. Check it with terminal extension. Make sure we get there. We have no impingement on the roof of the notch. No relaxation of our tension on our repair. So Postoperatively, these patients are on a relatively accelerated rehab protocol. I will initially brace them, but they will all typically discontinue the brace once they're ambulating with a fluid gait. Most patients that is somewhere in the 2 to 4 week range. They will start immediate range of motion and can transition to full weight bearing per their tolerance at the three month mark. If the patients can demonstrate a good and adequate single leg squat, they can gradually transition to running and resume their full activity.

Patrick A. Smith, MD (Naples, FL), demonstrates an ACL primary repair using the ACL Repair TightRope® implant and FiberRing™ sutures.

ACL Primary Repair Using the ACL Repair TightRope® Implant and FiberRing™ Sutures

So this is a left knee. And this particular specimen has a proximal ACL tear. You can see here's the ACL. This is the Anteromedial bundle. You can see almost a split with the posterolateral bundle. Complete tear off the wall. You can see the back notch area. And I think this would be suitable to a primary repair. My goal would be to put two good sutures with the fiber ring, one more toward the anteromedial footprint and the other toward the PushLock bundle here. And I'll show you that my first step is to prepare the footprint to get good healing. And for that I utilize the Arthrex PowerPick. So we bring the PowerPick in through my Anteromedial portal. We deploy it. And then what I like to do is kind of figure out where my absolute anatomic center of the ACL is. And there's kind of the over the top position here. So my first hole that I make is going to be where I'm going to place my fixation position for the TightRope, which will also have the internal brace. So to me that looks like a really good spot. So I like to make my first hole right there, and I'll kind of make that just a little bit bigger. So I can just make sure I can pass my spade through there. So I make my first hole there. So again, that's going to be my center of the ACL attachment. Then I proceed to make several other holes in the footprint. And I'll clear that debris out with our shaver. So you can see I've got the footprint nicely prepared now with those holes. You know, you could come in with a caret and do some further debridement, but I don't mind if I leave a few native ACL fibers still on the wall here to enhance the healing process. I think the PowerPick is enough to get good preparation. So our first step now, as we get ready to do our primary ACL repairs to create our femoral hole, which is going to be the passageway for the adjustable loop device, which has the attached FiberTape for InternalBrace. So remember I passed that first PowerPick hole at what I thought was going to be the center for my attachment point, which I think is really good right there. So I hold the spade tip. I'm coming through the anteromedial portal, flex the knee. So we bring our pin in about 120 degrees of flexion. So we're at the right angle. And then we drill that pin. As I said I drilled the spade tip from the anteromedial portal knee flexion 120 degrees out that center point on the lateral wall where I wanted my attachment point for my ACL fibers with the adjustable loop device and where the internal braces will be located. So now we simply pass a shuttle FiberLink through the notch of our pin. We'll pull the pin out and laterally here. So you can see now looking for the Anteromedial portal. That's my center point for the anatomic attachment of the ACL back to the femoral wall. I'm just going to come in through my lateral portal and just going to shuttle this out the lateral portal. And we just take a hemostat and we'll just stat that. So of course that'll come back through the amp portal with the passport later when we pass our TightRope. So there's our shuttle suture in the femur. I think optimal position to attach our primary fibers. And you can see externally here we've just passed it out the anterolateral portal. So now I'll go to the tibia to create my passageway for my shuttle, for my internal brace in the tibia, through the intact tibial stump. So to do so I utilize the tibial aiming device from our ACL set. And I like to position this within the anteromedial base of the ACL somewhere about right there. So make an incision on the tibia. I'll make this just a bit longer because it's a demonstration here. It's usually about a centimeter. And this is going to go down to the tibia. We'll clear off that periosteum. And this is where we'll fix our ultimately our SwiveLock for our internal brace. I utilize A24 small pin here to come out again primarily within the Anteromedial footprint somewhere about right there. So we bring our guide sleeve down to the tibia. So this is a two for cannulated pin. So through our small incision here's our guide sleeve two for Cannulated pin. And we'll watch it come in arthroscopically. Right in the middle of the guide. Perfect position. So at this point we will take our aiming device off. And then again this is cannulated. One little trick. If there's bone in the end of the pin, if you just rotate it in, it pushes the bone out by rotating the cannulated pin there within the larger pin. So now we take out that smaller pin and we have our cannulation opened up and we shuttle through a wire. And this will be our shuttle for the internal rotation of the tibia. We have the FiberLink on the femoral side and the wire on the tibia. So we thread the wire. I take my looped grasper There's our wire. So I'm just going to hold the end of the wire that I brought through the Anteromedial portal. And then we'll just back out the larger pin, which is again a small pin at 2.4. So now I have my shuttle from my joint side to the tibia for the internal base later on. And like I did with my shuttle switch in the femur, I like to now pass the wire out the anterolateral portal. So it's out of my way with my passport, and we'll just bring it back through later. So just a little simple step to keep it out of the way. So I bring this now out and we'll snap that. So now we've created our pathway for our FiberTape later on for the tibia as our internal brace. So the next step is we've got to place our ACL sutures with the fiber ring. And we definitely need a passport cannula so we don't get any soft tissue bridges. I like the eight millimeter size passport. This is a little bit larger than these. This is 40mm long. You could use a 30 and a smaller knee. So through the anteromedial portal we just insert our passport simply like that with our inserter. And now we're in. So there's our passport, and we'll put a ring on this one here just to give us good support on the skin. So now we're in shape to pass our sutures. So a very critical step is proper loading of the FiberRing. Here's a 25 millimeter fiber ring. This is going to be for my cinch suture through the ACL fibers. And the way you do this is you pass the fiber ring over the top of your fast pass Scorpion first in the next step is to take the free end and lock it into our fast pass. Scorpion. So now we're ready to go. We've got our fiber ring pass over the shaft of our Scorpion fast pass. We've loaded the free end so we can create our cinch. Our goal is to get a good bite in those proximal torn fibers. Generally, I'm about the mid substance of the ACL utilizing the 25 millimeter ring. If you had a situation where you needed a more distal bite toward the tibial stump, then I would go with a 35 millimeter long ring. But we're going to use a 25 millimeter, which is what I generally use for both of my suture passes. So I'm going to come through my passport cannula And again I like to pass one on each side basically. So I'm going to bring my Scorpion. Here's about the mid portion. You know here's the upper part of that tear. So I want to make sure I can advance fibers to the wall. So I'm going to come in here get a good bite within my Anteromedial bundle footprint right there. Capture it and bring that out and create our first synch so you can see how that was done. Now I'll just pull that free end now to synch it. I'll make sure I'm happy with that bite which looks really good. So that's my first pass. Now we're going to make our second pass loaded the same way. But this time I'll come from the other side. Now I'm going to make sure I grab some of the post lateral bundle. So I come underneath on this side now. Make my second pass. Captured in the jaws. Slide the FiberRing down and create my synch. So you can see. Now I've got two good cinches within that proximal ACL tissue. So I'm very happy with that. So here's the critical explanation for the technique of the adjustable loop device and how it works. You can see that distal to the cinches is this open loop. And that's the FiberRing. Again this was 25. If you had a 35 it would be longer. But this suture right here allows us to shuttle to create our TightRope, which we'll do outside the joint. So again the key here is the TightRope is not pulling on the sutures. It's pulling on the loop distal to the cinches. And that's how we pull our fibers up to the femoral wall to get a good secure primary repair and get tissue to the wall. So that's the key thing. And to do so we have the shuttle ring. So at this point they're wedged together. We're going to go ahead and cut the first one Just for ease of suture management, we can pass one of the FiberLink stitches out the anterolateral portal just to get it out of the way temporarily. So I'm going to do that here. The initial FiberRing is wedged together. We don't need that swedge any longer, so we're just going to cut that. And what I want to demonstrate I want to show you arthroscopically as well. You need to make sure that you have a free passage. You can see how it slides. So you want to make sure that the free end of the suture slides freely through that distal loop of the FiberRing. Because what's going to happen is this loop is going to transfer step one of our TightRope that we're going to make outside the passport through that ring. We'll pass the first one, and then I'll bring back the second one and pass it the TightRope through that one as well. But this is the mechanism. Just as a step, just always check and make sure that slides freely, which it does. So now here's our TightRope card outside the joint to create our BTB TightRope essentially. So we pass step one through the ring. And you'll see us pass that arthroscopically you can see it come through. So here's step one. That's through our first ring. Now we need to pass it through our second ring. So now I'm going to retrieve my previously passed second suture, which I just parked in the anterolateral portal. I'll bring that back out. The passport. Now, once again, we cut this wedge. We'll slide that suture, and you'll see it slides freely through the ring. So now we just do the same thing with step one, which is the black and white here. We're just going to shuttle that through the second ring. And you'll see that come through. So step one is bringing the loop of the BTB TightRope through both of the outer rings as you see there. So there's our loop. And we just did that with a passing shuttle suture that we cut off. Then we take step two from the card. We're going to pass that through the loop. So we pass step two. So now we're just going to pass an inch or two. And this makes it easier to pass and complete the TightRope mechanism. There. So that's actually our other shortening strand. And then we've got to take everything off the card. That's easily done by flipping the tabs here. You can see the blue FiberTape. Our InternalBrace is already attached to the button, which we'll show you in just a second. Here's our TightRope that we've created. And the first thing is, we wanted to make sure our shortening strands were equal length. You want to make sure you have enough length from the tip of your button, which we have plenty. So it passes out the lateral femur to flip the button. You don't want this to be too short. So notice the FiberTape is passed independently through the button already attached for you. And this is our passing suture for the button. So the FiberTape is going to stay here because that's going to ultimately be transferred into the tibia via our wire that I passed earlier. So my next step is I've got to retrieve my femoral shuttle suture, which remember I parked out my anterolateral portal. So we're going to get that loop. So I just bring my loop grasper through my Am portal. And I'm going to retrieve that shuttle suture right there. So now that loop we're going to pass the two blue passing sutures on the button and the two shortening strands for the adjustable loop. Tightrope, which is how we're going to pull those proximal sutures and the ACL fibers up to the wall. So we're just going to pass that. You can watch that come out. So we've passed with our femoral shuttle. We brought out our small little anterolateral skin incision. These are our two short strands of the adjustable TightRope. And these are how we're going to pull the fibers of the ACL up to the femur that we talked about earlier and allow for tensioning. So at this point I'd like to get a bit of slack out of the system because I want to pass my internal brace first and fix that before I do my final tensioning. So we're going to go ahead and take a little slack out of the system, which is going to going to be here with our button. We pass our button right there, get it to flip on the outside of the femur. So one way we can confirm that we're flipped with the independent InternalBrace on the TightRope. If we pull on the FiberTape hard, that button is going to sit on the femur. It also is very helpful for your post-operative x ray, because by pulling hard on these two fiber tapes, there will be no gap of soft tissue. You're pulling that button right to the lateral femur. You can see me pull hard on that femur. It's definitely flipped. So you don't need x ray because you've confirmed it with that manual pull. So what I like to do at this point is get a little bit of slack out of the system. So now watch as we pull the shortening strands. You'll see. We'll start to pull those ACL fibers up toward the femur a little movement of our white shortening strands. There you go a little bit more just about right there. You can see what we're doing. That's good. We'll stop there. That's the pull. And again this is really nicely seen on the video. The pull of the fibers is through the ring, not directly on the cinches. We just have reduced the slack in our shortening strands. But again, I want to first fixate the internal brace. So what I do now is I'm going to pass my wire that I passed earlier. So I come through my passport cannula, I grab my wire, which I parked out that anterolateral portal right here. Pull that back. So now I'm going to take the wire, and we'll pass the two ends of the internal brace through the wire. So now we're just shuttling the internal brace. You can see where it is in the tibia right there with the wire. So now I bring the internal brace out here. So there's my internal brace. And you 100% need to have an internal brace to do a primary pair because of the biomechanic stability it provides for the repair, sutures alone are not going to be enough. So there's my IB. It's kind of where I like to be. I like to be along the Anteromedial footprint there. So we're going to fix the internal brace first. So we're just doing our initial hole 4 or 5 or 5 hole for our SwiveLock. Anchor for our internal brace. You have to tap this bone. It is hard. So our next step is we're going to load the two ends of the internal brace through the eyelet of the 4.75mm diameter biocomposite SwiveLock anchor. So we take our slack out of the tapes. We bring the knee into full extension. And now we're going to remove the tap and put our anchor in place. So now we screw our swivel lock down hold the paddle again I do this in full extension. So now we back our swivel lock out. So now we'll just cut our fiber tapes here on the tibia. Here's our final step. Our internal brace is in place. And now we'll finish our tightening of our sutures up to the wall with our shortening strands. You can see the tissue gets pulled up very up very nicely as the slack comes out of the shortening strands, and I can fix this in any degree of flexion, which is critical. When I started, those blue cinch sutures were right here and now those blue sutures are way up there. You can see we've got a great repair here. Tissue to the wall. But what I like to do at this point is I cycle the knee so I can eliminate any creep in the system. And again, I can fix this in any angle and I'm tensioning it. And this is the advantage with the adjustable loop device we can retention. So at this point we cycle the knee I usually do it about 20 times. And we'll retension our shortening strands up on the femoral side to eliminate any final creep in the construct. You can see a little bit more we got there. So now when we probe it for you. So here's now our final product. And this ACL is super tight. You can see where I started I had a complete Sherman two tear to start with. You can see I've got tissue to the wall. I've done my PowerPick right through there. I'm going to get some stem cell egress around it. Again, look how far those sutures advanced. Those sutures when we started, were right here. So we've advanced about a centimeter of tissue up to the wall. It's anatomically attached. Don't have to ever think about a notch. Plasty. Totally anatomic, no graft. And the eib's in good position. Good tension on the IB, which is going to protect the repair. Full range of motion. Full extension. Flexion. I'll cycle again and again a couple of times over and over just to make sure nothing moves. Nothing shifts. I start range of motion right away. I like using a CPM machine actually. Early weight bearing. Once they can do a straight leg raise or off their crutches. So it's a really quick recovery. So that is the advantage of the Knotless adjustable loop device, allowing for retention with the new FiberRing system making it easier. And you have your internal brace which you absolutely need to protect the repair going forward.

FiberRing™ Sutures

Child (D)

FiberRings 

Secondary (C)