Knee

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The 4.5 mm-diameter bicortical post has an extremely low-profile head to reduce soft-tissue irritation. A 2.5 mm drill for bicortical post is used to broach the cortical bone, while the depth device provides accurate sizing information. The optional low-profile, spiked washer may be used in conjunction with the bicortical post for soft-tissue tendon fixation of soft tissue tendons directly to bone.&nbsp;
The posts and washers are manufactured using titanium ASTM F-136 alloy. The smooth, concave-shaped washer securely traps attached sutures and bulky suture knots atraumatically under the low-profile washer to eliminate potential soft-tissue irritation. The spiked washer facilitates direct soft tissue or ligament fixation to bone.
Ligament staples with a low-profile bridge reduce the frequency of secondary removal due to patient discomfort caused by soft-tissue irritation. The cobalt chrome spiked fixation staple has sharp leg points for easier penetration into cortical bone without predrilling. The staple driver with attachable impactor/extractor allows complete impaction since the staple driver tip is flush with the staple bridge. The staple seating punch may be used for further impaction. All staples are 20 mm.
Finally, the two-piece TensionLoc™ implant system is designed to fix suture during ligament reconstruction procedures. Using this technique, tibial suture fixation is shown for a single- or double-bundle anterior cruciate ligament reconstruction (ACLR). A unique alternative to standard suture buttons, the TensionLoc implant allows suture-button maintenance for suture tension adjustments during knot tying. The low-profile PEEK implant sits flush and securely within the tunnel.

Peter S. Borden, MD (Los Angeles, CA), demonstrates an ACL remnant-preservation technique using the TensionLoc™ implant system.

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Arthroscopic ACL Reconstruction With ACL Remnant Preservation

So prior to making the tibial tunnel, it's very important to breed all soft tissue off the periosteum. I prefer to make the tunnel in a diagonal direction such as this just lateral to the MCL. So this will be our target zone. There's plenty of soft tissue clearance, which prevents any sort of impingement of the outer collar when placing that up against the tibial tunnel entrance. So here you can see we have prepared the femoral socket already using a FlipCutter device. We have preserved the tibial stump. Now we're going to drill the tibial tunnel. And I like to place the guide directly in the center of the footprint and make sure that we don't get into our MCL. I prefer to preserve the ACL remnant. I think it's important for the anatomic landmark for the tibial tunnel, but also may help in faster graft, Innovation and vascularization. And you can see here that this is coming right up through the stump. And in reaming this, it's very careful that when you come through the proximal tibia that you take care and not blowing out the stump. So now that we have placed the guide pin, we are going to place the stepped collar with a ten millimeter diameter and a depth of about five millimeters. You can see that the soft tissue has been cleared, and this allows for the outer collar of the collar for an eight millimeter graft. So once this is seated we'll now switch to the eight millimeter reamer sizing the graft appropriately. So as I was saying it's important to clear the soft tissues around the periphery so that we can lay that collar of the outer piece of the TensionLoc directly on the tibial cortex. So here you can see I've been very careful in preserving the stump. And you can see that the the reamer has passed all the way through. And we'll take care in removing this with the hand. Try to preserve the stump as best as possible. Perfect. So we're now going to pass the sutures down the tibial tunnel and advanced our graft. So now we will pass the TightRope. So what I have done prior to passing the TightRope is I've placed a TigerWire through the button and kept it down with the tibial sutures. And now I'm able through the medial portal to retrieve these. So that we can pass these later through the stump and advance this superiorly towards the femoral tunnel. So you can see our tiger wires coming out. This actually brought the stump up just with the tension of the graft. And now we're going to fix this on the tibial side with the tension lock. And then we'll come back. And with a Scorpion we will repair the stump and try to pull that up towards the femoral socket. When we prepared the graft we put a total of four sutures, and we color coordinated them with TigerWire and the blue standard FiberWire, so that when we tie our sutures from 6:00 to 12:00, after the inner peace has been impacted, it's just a lot easier to coordinate the heights of 12 to 6. As you can see now we're going to pass these through the outer collar. I'm going to seat the outer collar there. And then I'm going to come back to my color coordination. Now impacting the outer collar. Here you go. These don't need to be very tense. So the impactor has a slot here at the collar at the 12:00 and 6:00 position. And so you want to position the sutures in the same position before impacting. So you see, we don't want to crush the bone and we don't want to break the implant. But this is adequately secured. And now we're going to take the inner piece. So now we're going to position this where the slot lines up with the 12 and 6:00 position. Now my assistant is going to tension the sutures. I would encourage you not to over pound it. And there you can check it. Whether it's locked. Now, what I normally do before I tie is I'll test the stability. And I like to put the scope back in the joint, confirm our position, perform an anterior draw. And then confirm stability of the graft before I tie. And now we suture 6:00 to 12:00. And we tie all four strands. Now, I like to keep one limb from each 12:00 6:00 position. And after I'm done, I'll sometimes use this to repair the sartorial fascia and soft tissue over the TensionLoc. And that also will prevent in people that have very little bit of subcutaneous fat, it will prevent any sort of suture irritation with activity and kneeling. Okay. Now everything has been fixed on the tibial and femoral end. We have excellent stability. The graft is sitting right where we want it and the stump is enclosing the bottom portion of the graft. So we have our two TigerWire sutures. And now we're going to place a cannula through the medial portal. And we're going to try to repair part of the stump back up towards the femoral attachment. So through a passport cannula we will bring the Scorpion in. So here you see a repair of the stump anterior to the graft. We have an excellent stability with Lockman testing and anterior Answered your testing. And now using TightRope, if we need to retension the graph, we can't. That's excellent. So here you see no Cyclops lesion concerns, great stability and soft tissue coverage of the graft. So here we're throwing in one more stitch. For completion of the repair. There we go. And here's the final product after stump to ACL repair. So that is an ACL hamstring reconstruction using TightRope fixation and TensionLoc tibial fixation with stump repair.

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TensionLoc™ Implant System Single-Bundle Surgical Technique

TensionLoc™ Implant System for Ligament Reconstruction

Peter S. Borden, MD (Torrance, CA), discusses using the TensionLoc™ tibial implant for ACL reconstruction cases that include tibial stump preservation and repair.

ACL Reconstruction With the TensionLoc™ Tibial Fixation Implant

Hi, I'm Pete Borden from Los Angeles, California, and I'm going to talk about ACL reconstruction with the Arthrex TensionLoc tibial fixation implant. When I perform ACL reconstructions, my primary goal is to restore ligament stability with enhanced healing and preservation of biomechanical and anatomic properties, which is why I like to preserve the ACL native stump and implement an early accelerated rehab program by preserving the stump. This can act as an anatomic, landmark or guide for tibial tunnel placement, and may accelerate the revascularization of the graft and contribute to faster graft, reinnervation and accelerated return of proprioception. It has been shown that the stump can decrease synovial fluid leakage into tibial tunnel, decreasing tunnel widening or premature Bio-Corkscrew breakdown. The TensionLoc tibial fixation implant consists of a two piece peak system with an outer and inner piece. Once the ACL has been fixed in the femoral side, the sutures from the tibial graft are then placed through the outer piece, which serves as a protective collar which is inserted in the tibial tunnel entrance against the outer tibial cortex. The sutures are then tensioned appropriately and the inner peace is impacted into the outer peace. Securing FiberWire, SutureTak or SutureTape against the outer collar inner wall. Tying sutures or tape over the inner peace after proper placement provides a secure backup fixation. Other potential surgical indications for TensionLoc other than ACL reconstruction would include PCL reconstructions, meniscal transplants, meniscal root repairs, tibial eminence repairs, SutureTape internal brace, and complex revision ligament reconstructions, especially with poor bone quality. So the advantage of TensionLoc over interference screw fixation is that it promotes circumferential tunnel graft healing, and it avoids the potential complications of graft necrosis, twisting or advancement proximally of the graft, which is associated with interference. Screw fixation. Tensionloc seals the external tibial tunnel, decreasing subcutaneous hematoma, formation and loss of the natural healing factors or added biologics. Tensionloc accommodates shorter grafts. This allows for shorter bone plugs and less harvest site morbidity and possibly larger diameter soft tissue grafts using the GraftLink triple strand suturing technique. Tensionloc versus interference. Screw fixation is shown to have double biomechanical pull out strength, and I have noted anecdotally that the patients are having less post-operative pain immediately, which results in faster and more aggressive rehab. This is a case of a 30 year old male who had a non-contact basketball injury tearing his ACL. We elected to fix the ACL with a hamstring autograft. We obtained an eight millimeter femoral graft and a nine millimeter tibial graft with a length of 60mm. The graft was fixed on the femoral side with a TightRope, and the graft was fixed on the tibial side with the TensionLoc. We preserved the ACL stump, and following repair and reconstruction of the graft, we repaired the stump to the ACL graft. Here's a slide in the upper corner that shows four FiberWire sutures placed in the tibial end of the graft. And this is looped over the TightRope button. The slide on the left demonstrates the tibial guide pin placed Anatomically through the stump of the ACL. And the second slide shows the graph fixed on the femoral side. This next slide shows for FiberWire sutures at the 12:00 position, and for FiberWire sutures at the 6:00 position, and these are properly tensioned while the inner plug is impacted into the outer plug of the TensionLoc. And the slide on the right shows all four strands superiorly at 12:00, and all four strands at 6:00, which are now to be tied over the inner plug, securing the backup fixation. The slide on the right demonstrates a repair of the stump to the graft following proper fixation. This was performed using a Scorpion or a suture passing device using a FiberWire suture, which was tied arthroscopically. The video on the right will show what this looks like. With flexion and extension of the knee. You'll see there is no evidence of Cyclops lesion. You have excellent approximation of the stump to the graft and you'll see an intraoperative anterior drawer test with excellent stability of the ACL reconstruction. Here's the second case in the slide on the left shows proper placement of the tibial tunnel. The slide on the right shows a CrabClaw grasper grabbing sutures that have been placed through the TightRope fixation device prior to advancing the graft in the femoral tunnel. These sutures are retrieved through the medial portal and to be used later to to repair the stump and advance this towards the femoral tunnel. The next slide shows a Scorpion device passing the suture through the stump, and the slide on the right shows repair of the stump and advancement towards the femoral wall. Here's the third case, which illustrates a similar process. And the slide on the right demonstrates almost a perfect approximation of the stump to the femoral wall covering the anterior aspect of the graft. My post-operative protocol consists of weight bearing as tolerated post-op day number one and a post-op brace locked in full extension. Straight leg raises of greater than 200 per day. Day of surgery and the first post-op visit is within 2 to 3 days, and the patient must sleep in their brace, locked in full extension for the first three weeks. I start physical therapy within 2 to 3 days following their first post-op visit, emphasizing range of motion and strengthening, and we unlock the brace when they have adequate quadriceps control. The second post-op visit is approximately three weeks, and the patient is then placed in a functional brace and emphasized to perform stationary bike exercises five days a week, plus their physical therapy as they progress is tolerated. Patients may begin running at 3 to 4 months if they have normal range of motion, and return to cutting sports after six months. In summary, the TensionLoc implant provides superior low profile tibial fixation with or without stump preservation. However, preservation of the tibial stump may potentially result in faster graft incorporation, reinnervation, and healing with an accelerated rehabilitation and return to normal activity. Thank you.

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