Knee

Procedure

Lesões relativamente incomuns do joelho, as fraturas por avulsão da espinha tibial normalmente ocorrem em crianças e adolescentes.1 Apesar da baixa incidência de fraturas por avulsão da espinha tibial, elas merecem atenção plena para garantir que a função e a estabilidade do joelho sejam restauradas corretamente.
As inovadoras suturas FiberRing™ fornecem uma técnica simples e reprodutível para fixar a parte remanescente distal para obter redução anatômica. O implante ACL Repair TightRope® oferece fixação sem nós regulável para garantir que o comprimento do LCA seja restaurado e mantido adequadamente.
Por fim, o aumento do ligamento com InternalBrace usando um botão para LCA que acomoda o FiberTape para ajuda a impedir o excesso de amplitude de movimentos durante a fase de cicatrização e potencialmente reduzir a possibilidade de uma segunda lesão.2,3
Referências
1. Williams NR, Yin S, Guzman AJ, et al. Tibial spine avulsion repair with FiberRing suture and anterior cruciate ligament repair TightRope.&nbsp;Arthrosc Tech. 2023;12(12):e2381-e2385. doi:10.1016/j.eats.2023.08.008
2. Mackay GM, Blyth MJ, Anthony I, Hopper GP, Ribbans WJ. A review of ligament augmentation with the InternalBrace™ the surgical principle is described for the lateral ankle ligament and ACL repair in particular, and a comprehensive review of other surgical applications and techniques is presented. Surg Technol Int. 2015;26:239-255.
3. Smith PA, Bley JA. Allograft anterior cruciate ligament reconstruction utilizing internal Brace augmentation. Arthrosc Tech. 2016;5(5):e1143-e1147. doi:10.1016/j.eats.2016.06.007

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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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.

Rachel M. Frank, MD (Denver, CO), demonstrates the reduction of a tibial spine avulsion fracture (ACL tear equivalent) using the ACL Repair TightRope® implant and FiberRing™ suture.

Tibial Spine Avulsion Fracture Reduction Using ACL Repair TightRope® Implant and FiberRing™ Suture

I'm Rachel Frank, a sports medicine and shoulder surgeon from the University of Colorado in Denver and Boulder. And today we'll be discussing a new technique for tibial spine avulsion fracture fixation. So here we have a left knee with an acute tibial spine avulsion fracture that you can see here. My arthroscope is in the standard anterolateral portal. And my probe here is through the standard anteromedial portal. We can see anatomic landmarks including the medial femoral condyle, the posterior cruciate ligament, the anterior cruciate ligament and its attachment on the femur is healthy and normal. But we can see there's slack and redundancy in the ACL due to it being avulsed off the tibia with this tibial spine avulsion fracture here. And we can see that entire fracture bed right here. And that goes, you know, fairly deep. And this is pretty classic for a tibial spine avulsion fracture. And we can even see that the anterior horn lateral meniscus is attached to that piece. But once we get the piece nice and reduced like so, and then secured with our construct, we construct, we will be able to restore the native tension to the ACL and essentially have an anatomic repair construct. Sometimes you do have to do a little bit of removal of some of the bone, especially if it's more chronic to get the fracture to reduce and sit down nicely. But in this case it's acute and we should be just fine when it comes to getting the fracture to sit down nicely. So we're going to put in our ACL guide. And essentially we're going to want the Pin to come out right through that bone. So we're using the guide here to reduce the ACL footprint back to the tibia. We're going to push the bullet up to the skin. Make a little indentation. Good. We'll take that out. I'm going to move the guide over. I'll take the knife. And then I'm going to make an incision. And this is essentially just medial to the tibial tubercle. And I'll go straight down to bone. So then I'll take the guide back and again get it centered right where I want it. So we'll use our guide right here. So now we're drilling the pin up and we've already gone through the tibia. Now we're going through the fractured piece. So now we'll leave that in. So at this point then we will loosen our guide, take it off so that we have a little room to work with. And then what we'll do is we'll unscrew and we'll get our lasso wire ready to pass up. And then we'll get a loop retriever ready. So then we'll pull this out and then we'll shuttle up the wire. And I'll turn the water off just to help get that wire up a little bit easier. And I will go grab and retrieve this with my looped retriever. We'll pull the pin out so we don't accidentally lacerate our wire. Good. And then we'll retrieve this out the passport. Secure those and snap those together. We're going to fix our tibial spine avulsion fracture with our knotless TensionLoc FiberRing suture. Acl repair. Tightrope construct. As you can see here, we've loaded onto the Scorpion the fiber ring in a looped fashion to essentially create a luggage tag. And we have the free end of our construct in the Scorpion. So then we'll load this through the Anteromedial portal. We will pass this around the ACL. And we'll pull this through similar to doing an ACL repair. And so now we can see we have this secured quite nicely using this fiber ring in a luggage tag fashion. And the beautiful part about this is we don't have to go back and forth and back and forth with additional suture throws or passages due to the biomechanical properties of this particular fixation construct. So now we're going to load up a second one, but I'm going to pass it through the opposite portal so that we can really get some good compression around the ACL. There we go. So now we're viewing through the Anteromedial portal and working through the anterolateral portal. And we'll go essentially just above. And we'll shuttle that through. I'm going to switch my scope back to our standard anterolateral viewing portal. And I'll take a looped retriever and we'll go get this out the same portal. We've essentially passed our constructs through the ACL. We have our tunnel through the tibia and through the tibial spine. Avulsion fracture. The next step is to then shuttle our sutures, and we're going to use O. Fiberlink sutures in opposite directions, opposite colors to do that. So you can see here we have the loop of one FiberLink and the tail of the other FiberLink. And we're going to shuttle those through our lasso wire like so. I'm going to do a little pinch for security, and then we'll get those shuttled through. And I'm going to hold on to these guys. We're going to use these opposite shuttling mechanisms of these O FiberLoop sutures to manage our constructs. So now we're going to use our ACL repair TightRope in order to shuttle these sutures. So we're going to take the leader suture, which is the tiger striped suture here out of slot number one. And then we're going to pass that through the O FiberLoop. So now we're going to shuttle that through. You can see we've come out nicely. We're all going to be working now outside the joint. We're doing all of our suture shuttling outside the joint. Now what we're doing for suture management is getting one of our devices, one of our constructs, out of the way to make sure we don't have any tissue bridges or twisted sutures. So I'm just retrieving it outside the passport and docking it. The next step here is we're going to cut the swaged portion of the FiberRing suture tails so that we can effectively shuttle our device. Next we're going to take the leader suture and place it through the eyelet islet of our construct. And then we'll shuttle. The next step is going to be to retrieve the second fiber ring that we previously docked for safekeeping outside the passport. Good. And then now we're going to cut the swaged ends, just like we did with the first one. And we'll go ahead and cut. Leaving length. Next we're going to repeat what we just did and load our TigerWire leader suture through the eyelet of our second device. Okay. And we'll shuttle that through. We have both of our devices around the ACL and effectively passed through the stump. The next step is now going to be to get our FiberLink tail that we docked outside the lateral portal, back out our medial portal so we can effectively shuttle these sutures down through the tibial tunnel and of course reducing our tibial spine avulsion fracture. So here we have the looped portion of our suture. And we'll go ahead and grab. Our tail. We'll give it a little bit of a pinch and then we'll shuttle. We'll give a little tug. And so now we can see that we have two of our ring devices around the ACL. Our ACL tibial spine avulsion fracture will be adequately reduced once we secure our TightRope, because we'll be able to secure our TightRope and pull tension, just like they never had a fracture at all. So the next step is going to be to be to cut the loop of our leader. Suture. And then we're going to use our ACL repair TightRope and build it. All right. So we're going to take the white single tail off of the assembly card here at slot number two. We're going to pass that through my loop here. And then we'll pass that through the wire. And then we're going to give a tug on the blue tag at this point. Now we're going to unclip everything on the back of the card. So I'm going to turn the card over. Fold these up and unclean everything. So next we're going to remove the FiberTape as it is not necessary for this procedure. So now we have taken our button off the card. We have removed our FiberTape and blue suture as they're no longer needed, and we're now going to reduce the fracture and secure our construct by reducing the button and tensioning it down to the bone. So what I'm going to do to make sure that I'm getting adequate and even tension is I'm going to first make sure that the tails are the same as we start. And then I'm going to mark so that I can get a good idea to make sure that I have the same amount. All right. So we'll continue to go. And you're going to slowly extend the knee to help reduce the fracture. So here you can see our repaired ACL tibial spine avulsion fracture. There is if I do say so myself excellent tension on the ACL itself. I mean I'm pulling on that and that's nothing. You can see I'm pushing on it and it's not moving. Its attachment into the avulsed spine is anatomic and our avulsed spine is perfectly Reduced, which can be difficult, especially in a somewhat subacute or chronic situation. Because these patients can often have callus forming just like a regular fracture. And that callus can certainly get in the way of an anatomic reduction here. I think the combination of the technology, this ringed suture really helps secure the base of the ACL through the fracture bed and then through the tibia, and essentially a biomechanically and anatomically robust final product. And at this point, once we're happy with our fracture reduction, which I'm very happy with our fracture reduction, we can actually cycle the knee as we would, for example, with an ACL reconstruction or repair. And you can see here I'll actually have you show that one more time as you're cycling. First of all, the fracture is not moving whatsoever. Second of all, in full extension there at the top of the screen you can see that we have no impingement. So oftentimes these patients have the complication of stiffness after surgery and inability to achieve full extension, and they may require a lysis of adhesions following adequate repair of the fracture. Here, as we cycle again, we have absolutely no gapping in the fracture site. I'm not holding my probe down there. The fracture is remaining perfectly. Let's have you go up and back a few times. The fracture is remaining perfectly reduced to the tibial plateau and in full extension, which we're at here. There's absolutely no roof impingement. And then we come down to flexion and there's no gapping. And then if we wanted to, we could come back out to about 20 degrees of extension and we could retension the ACL. And you can see that. And we can get a little bit more after cycling and getting out the creep. Minus those beautiful blue sutures. It's as if we were never here.

Daniel W. Green, MD (New York, NY), demonstrates a technique for tibial spine avulsion repair using FiberRing™ sutures and the ACL Repair TightRope® implant.

Hello. My name is Daniel Green from New York. Today we'll be reviewing the suture treatment or suture based technique treatment for tibial spine fractures. And we'll be using fiber rings and the repair TightRope device. All right. So we're looking here at the arthroscopic video. And we're in the left knee. And when we're assessing the tibial spine fracture one of the first things we've done is we've debrided the fat pad and all the areas to allow visualization of the inner meniscal ligament and the anterior horns. And here we can see that, as is common, the inner meniscal ligament and the anterior horn of the medial meniscus are very close to the fracture fragments. Sometimes we need to put a a grasping device or a hook a suture or a hook underneath this meniscus to pull it forward, to get it out of the way. And in this case, in our simulated fracture, doesn't look like it. The other assessment we do is to make sure the ACL behind the fracture is intact. And here the ACL does look intact. And here you can see our fracture line goes from the medial plateau junction. And it goes and extends underneath the anterior meniscal root and extends over here. So here's our fracture the tibial spine fracture that would be treated today. Now in this situation we have an acceptable reduction. We can see that this is a movable fracture. We can get underneath it and get some debris out. And then we're going to take our tibial ACL guide and pull this down. So we have an acceptable reduction. We're going to put two small tunnels to facilitate suture placement on our proximal tibia. The first one medially will will will put a little more distally on the tibia. And our second one laterally will be a little shorter on the proximal tibia. And we'll have kind of two parallel small tunnels for, for to handle our two sutures. So first we'll pass the guidewires and we'll demonstrate that now. So I'm going to get a tibial ACL guide. I've set this first one On 70. And you and you guys get ready to make a skin incision if you want. Kind of the standard ACL sweet spot. We don't want to be too. That looks good. So this is I can I'm just feeling the joint line. I got a good distance. I'm definitely in the metaphysis. This is on the long side. Now, where do we put these guidewires? We want to be in the fracture fragment, but we don't want to be too far back. We'll control the anterior lip better if we're in the front half of the meniscus. So let's pass this wire now. So this is the two four cannulated pin. Go a little harder. Okay. So we just passed our our medial two four cannulated guide pin for our medial tunnel. Notice we're in the medial side of the ACL. We're in the front of the ACL but still in the body. And this is going to allow when we do our Scorpion passes here for our tags for our fiber rings. This will be a good placement for our medial construct. Now we're going to go and place one laterally. We're on the lateral side of the ACL. And look at the proximal tibia. Come on in here. And George we're going to go through the same skin incision. We want to show you this because we're on. We don't want to be right on top of our medial tunnel. So we'll go through the skin. And then I'm going to rotate my hand a centimeter medially. And on purpose we did. We changed our angle ten degrees. So we're also shorter. So we're about a centimeter from the first pin and about a centimeter lateral and a centimeter proximal. So that's where we like it. It's all through the same skin incision. It's not perfectly parallel but it's parallel like. And we're going to go in about 25 30mm. The other thing I wanted to show you, just while we have that view, is how far we are from the joint line. So here's the joint line. And we got a good 20, 30, 20, 30mm from the joint line. Okay. Here's our two four cannulated pin coming in for our lateral small lateral tunnel. And it's okay that this is in the anterior part of the fragment. Because this is the part that usually kicks up. We want it to be in the anterior part of the fragment. But we obviously remember the tension of it, the strength of it. It's going to be the body stitches in the ACL. So this location is good. All right. So now just to, just to review, we have our medial pin placed. That's cannulated right here. Right there. And we have our lateral pin there about a centimeter apart. So it's what our goal is. Now we're coming in with a 35 FiberRing know the needle is going to start medially and exit laterally if you don't have enough room here. And then sometimes I'll go into the figure four position. But it looks like in this case we're having enough room here. I'm coming in through the medial portal. The needles come in medial. I'm rotating my hand to avoid the condyle, and I am grabbing at least 50% of the ACL, advancing the needle. Now, you see, I avoided the condyle grabbing it, and now I'm pulling that through. So this will be our medial FiberRing. And it's the length of 35. Now let's I'm going to switch the scope around. Let's go from the other side. I'm coming in now from the lateral side. Again, I'm trying to get most of the ligament on this side without getting my previously placed fiber ring. So I'm going to go right above it a little bit deeper. Angulating my Scorpion. So the tip is away from the condyle and we get a good pass here. So this is an important step of now we're going to take out the inner cannula the inner device of the cannulated wire the trocar. Now we're going to advance our flexible nitinol wire up. And once I see a little wire I'll switch to a grasper. Good. And just hold a little tension on that just a tiny bit. Okay, so now I have it outside. So before we can shuttle, we need to remove the cannulated guidewire. So we do that just by using a needle driver and pulling it back. Now we have a larger hole in the tibia to facilitate our suture. So the guidewire has been removed. Now we're using the flexible nitinol wire to pass our suture. That's holding onto our ring down the lateral proximal tibial tunnel. Oh, look at that. Nice tension on the ACL. Now we have to do the same thing on the medial side. Okay, so now we've passed our lateral luggage tag down the lateral proximal tibial tunnel. Now we're focusing on the medial side. So we're taking out the inner portion of our cannulated Guidewire. Now we're putting up a flexible nitinol wire. Good. And one of the big advantages of this of the TightRope system at the end here will be we'll be able to sequentially keep tidying it. We just want to have one tightening. We'll be able to cycle the knee and keep working on the tension of the remnant ACL. Again we're removing the outer portion of our cannulated guidewire before we shuttle it down. Now we're on the outside of the knee. We're going to put our suture tips through the loop of the flexible nitinol wire. And here we go. We've passed both sutures through the tibia. Can you sequentially tighten one or the other. And let's see if we notice a difference in the ACL behind it. So look at the lateral fibers of the ACL. Look at the medial distal fibers. So do them both. So it's really the key here is we want to end up with this remnant ACL behind it under good tension while also maintaining a good fracture reduction. We don't want the lip of this to come up. And so we have to keep an eye on this anterior lip to make sure it doesn't come up. So now under tension you can see it's starting to look better in the front. And this is a non articular surface. So you can have a little gapping here. I've already purposely debrided some of this so we could see our fracture better. But look at that. Tension is nice. So I put in a probe underneath my fiber ring. And I can see the end of the fiber ring suture passing stitch. And this will just help in a minute. As you'll see down below. We're cutting the loop. Now we have our ring. We're going to we're going to floss. And this will help just facilitate our tunnel for passing. Now we're going to take number one inch our card and place it through our passing ring. Okay, here you can see on the ring of the passing stitch. And we're putting number one of the stitch through it. Great. Now we're going to. Now we're going to focus our eyes to the ring itself. We're here we go. We're going to pass that number one around the ring now. Okay. Number one is pass through. It's important to do this step this way so you can see the repair implant pass around the fiber ring, the bulky part of the implant. Nice. Now we're cutting the leader passing suture off. Now we're assembling the rest of the repair TightRope or ACL TightRope. Now we're using step three of the card passing that stitch through. Now we're going to release everything on the back of the card. And because we're already have an incision on the on the tibia here, we don't need our passing stitches on that. And it's very important to balance this before you start to tighten it. Balance the sides of it. One nice pearls to remember. Have your assistant give you some counter traction as you bring your TightRope button down and equal pulls on each side. Good. We're just going to knot final. Tighten it. Now we're going to put in our medial one. Now. Now we've passed our lateral TightRope device through the proximal tibia. We have not done that on the medial side. So remember it's important to see the ring suture passing junction when you do this. Otherwise it could get. It needs to act like a pulley. You need to pull it up, otherwise it could have difficulty passing. So this is a key step. Now we're starting. Now he's flossing the tibial socket. He's going to cut the suture passing loop. Use the eyelet to put the first suture of the TightRope number one on the card around this ring. So we're going directly from the card of your ACL TightRope to a fiber ring. Again, in order to do this you need you really need to see the ring suture junction. There's there's the cause. See how thick that suture is. So you need to make sure it's past the ring or it gets cut up. I think I can let go now. And he needs a little tension so it doesn't get stuck into the small socket that we made. Now we're cutting the lead suture off. And he's taken number two through the suture, passing blue tab on the black card. And now he's linked it up. We've got an ACL repair link working here again. Since we're on the outer, we have an incision on the outer side of the the cortex. We don't need the blue passing stitches, so we'll remove those. Now we're going to get balanced before we start tightening we're pulling back. Let me get you some tension between the loop. Let's see how it's behaving immediately. Look how it sucks. They see how two rings look better than one. So now we have both our repair tightropes coming through two separate tibial sockets. And the question might be, well, what about the orientation on the tibia. What about the orientation of the buttons? It really doesn't matter about the orientation of the button that much, except because you've already set it with your tunnel placement. It's very important. You can see now to have those two proximal tibial tunnels starting about a centimeter away. You don't want them five millimeters from each other. You want about a centimeter. And then it just sort of works itself as you tension it. The other thing, what about knee positioning when we're touching it? I kind of think of it as an ACL tensioning. So I like to bring the knee in a bit of extension close to 30 degrees, and then we can go back and forth, back and forth, back and forth. Unlike and continued attention, the remnant ACL. So it ends up being a I think a way superior tensioning Technique than just using a button or an anchor distally on the tibia. I don't like this move. And you see the importance of having these sockets or tunnels come on the anterior part of the tibial spine. You need to cheat a little bit anterior on your sockets, because the the ACL is going to find that, that zone of of exit. So let me just show you on the probe. So if our tibial. So here's the fracture. Our sockets are kind of in this zone. If we had our sockets any further back it'd be kind of non anatomic. Now I'm going to turn the scope around so we get a better view of where we're talking. So here you can see our look at how tight that is. It's crazy. It's tighter than when we started. Okay. Let's do our final tight. And let's see we haven't finally tightened yet. Let's do a little bit more on the medial side. See if there's any more to give. Good lateral side. Good. Here we can see this is at the end. We see the nice tension of the of the ACL we've had we placed recalled at the construct is involves and the steps involved. We use two sockets in this case or two tunnels. That is in this case with the cannulated guide wires. We placed two fiber rings. We then visualized the fiber rings in the knee to allow passage of the ACL TightRope device. So it didn't get didn't get caught up. And then now we can with the ACL TightRope device, we sequentially tighten this after cycling and range of motion. So it really got superior tension on the remnant ACL. So it's a really nice technique to consider when when performing tibial spine fracture repair.

Reparo de avulsão da espinha tibial

Reparo de avulsão da espinha tibia