In the Loop: ACL Primary Repair
Biocomposite SwiveLock® Anchor and Labral Scorpion™ Suture Passing Technology
There has been a recent resurgence of interest in the possibility of primary repair as the treatment for certain patterns of ACL rupture. Historically, the technique of primary ACL repair was largely abandoned by the mid-1990’s due to marginal clinical outcomes. However, careful analysis of the older data reveals that certain subgroups, especially proximal tears with good tissue quality, had better clinical outcomes than the group as a whole.1
|Suture passage through the ACL tissue begins at the intact portion of the ligament and progresses towards the avulsed end. Begin by passing a #2 FiberWire® suture using the Labral Scorpion suture passer. After the first pass, alternate passes with opposite ends, thus creating a Bunnell-type stitch pattern. In a normal length ACL, a total of 2-3 passes can be performed with each limb of the FiberWire suture. The final bite should exit the avulsed end of the ligament to ensure that the tissue sits down flush to the repair site.||The same technique is performed using a #2 TigerWire® suture. As more passes are performed, the risk of transecting already placed sutures increases. Once the Scorpion suture passer is placed for a suture pass, the surgeon should get tactile feedback of increased resistance attempting to pass the suture if he or she is intersecting a previously placed stitch. If this occurs, the Scorpion suture passer should be redirected and suture passage reattempted. Again, the final bite should exit the avulsed end of the ligament to ensure that the tissue sits down flush to the repair site.||Once the sutures are passed, and control of the stump has been achieved, the sutures are parked out an accessory stab incision to retract the ligament away from the reattachment site. This allows both the ligament tissue and the sutures to stay out of harm’s way while the reattachment site can be prepared with a shaver, a burr or a PowerPick™ resector (inset).|
|Create an accessory inferomedial portal that will allow placement of the suture anchors directly into the femoral footprint. Through this portal, with the knee in flexion, 4.5 mm x 20 mm drill holes can be made to place the anchors. The anchor pattern should be optimized depending on the pattern of tear, much like a rotator cuff repair. This will be an intraoperative decision. Note: Some surgeons prefer to visualize the ACL femoral footprint via the medial portal to optimize visualization and placement of the drill holes and anchors.||Load the sutures into the eyelet of the 4.75 mm SwiveLock anchor. Introduce the SwiveLock anchor through the medial portal, insert into the ACL footprint and tension the SwiveLock sutures. Advance the driver into the bone socket until the anchor body contacts bone. Advance the screw by holding the thumb pad as the inserter handle is turned clockwise.||When the SwiveLock anchor is fully implanted, the eyelet of the anchor is fully seated in the socket by the body of the screw portion of the anchor and the sutures are fixated by the pressure of the screw. Unwind the tip retention suture from the cleat at the back of the driver handle. Remove the driver. Pull one limb of the retention suture to fully remove it from the implant. Cut the free suture ends with an open-ended suture cutter so that they are flush with the edge of the bone socket.|
1. van Eck CF, Limpisvasti O, ElAttrache NS. Is there a role for internal bracing and repair of the anterior cruciate ligament?
A systematic literature review [published online August 1, 2017]. Am J Sports Med. doi:10.1177/0363546517717956.