Name: Revision ACL Reconstruction Using the FlipCutter® III Drill
Uploaded: 2020-06-04T00:00:00Z
Channel: Arthrex

J. Lee Pace, MD (Farmington, CT), demonstrates a single-staged revision ACL reconstruction using the all-inside QuadLink™ technique, during which he uses the FlipCutter® III drill to remove the previous soft-tissue graft and create new sockets. The FiberTag® TightRope® implant facilitates attachment of quad tendon grafts to the ACL TightRope RT and ABS implants. The TightRope implant's proprietary 4-point locking system allows one-way shortening of the loop to maximize graft-to-socket contact and allows graft retensioning.

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VID1-001188-en-US | B | Revision ACL Reconstruction Using the FlipCutter® III Drill

J. Lee Pace

Human

A video recording of a surgical technique on a live patient in an operating room setting or a cadaveric demonstration.

Eine Videoaufnahme einer Operationsanleitung an einem lebenden Patienten oder Patientin in einem Operationssaal oder eine Demonstration an einem Humanpräparat.

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Surgical Technique Videos

Gravação em vídeo de uma técnica cirúrgica em um paciente em uma sala de cirurgia ou uma demonstração cadavérica.

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Grabación en vídeo de una técnica quirúrgica de un paciente en un quirófano o una demostración cadavérica.

Videos de técnicas quirúrgicas

Revision ACL Reconstruction Using the FlipCutter® III Drill

What we want to demonstrate here today is how to perform a revision ACL reconstruction using the FlipCutter three. In an all-inside technique. So we've created a situation here where we have a graft an ACL graft that's in pretty good position. That's a pretty good femoral tunnel right there. We've got a good tibial tunnel. We can show it right there. And you can see there's a graft in there. So we've got good tunnel placement here. We'd like to do a single stage revision with the quadriceps tendon autograft here. And we'd like to use the FlipCutter three to keep this minimally invasive and also preserve as much bone stock as possible when we ream this graft out so that we don't inadvertently widen our tunnel. And we can still do this in a single stage. So you can see we've got our cut ACL graft in place here, and we're going to come in. And as a first step, try and create a slightly divergent femoral tunnel with the exit point on the femur a little bit different but the but the entry point into the joint pretty much the same. So first step, we'll insert our passport cannula here like that. And then we'll switch our portals. And we'll bring our six nine guide in like this. And again we like our tunnel sort of hug the existing graph tunnel just like that. Okay. And we've set our angle a little bit more horizontal so that we can try and avoid the exit point that we had from the first reconstruction. Okay. So that looks pretty good there. So we'll put our FlipCutter three in. And there we have it. So as you can see we got the FlipCutter exactly where we wanted it to be. And you can see it's already wrapping up graph which is what you want to see because we're going to use this to remove the current ACL graft tissue that's in there. So I'll take this out and we can mallet the drill sleeve in place. And then as needed, what you can do in a situation like this is I can switch my camera and I can come in with a shaver or a grasper, and you can just start removing some of this tissue off of the FlipCutter as it comes. And in a lot of situations, you may have some suture that gets wrapped up with the FlipCutter as well. The FlipCutter tolerates the suture very well, and you can just remove it with a grasper as you're doing this. And it's actually quite easy. So you can see here we're just kind of getting all the graft material off of the FlipCutter. And there you can see it just like that. So what we're doing here now is we're in the joint. I've switched back to the medial portal and we're going to open the FlipCutter three up. Now what we can do is we can start this by going up to a six millimeters. So we'll open it up from three 5 to 6. And then we can just ream into the tunnel with this get our initial amount of graft out. And then we can upsize from there. So, you see, we can pull back and then we can push back into the joint a little bit by power, a little bit by hand. If it's a little bit tough, just, you know, very just deliberately push in. You can see we've got some extra graft wrapped up around there. So I'll switch portals, come back and we can just sort of remove this graft off of here. And in a real situation, in a live situation, this graft has healed into the tunnel. So this this cadaveric demonstration is a little bit different because we don't have any graft healing in the tunnels. But when the graft is healed in the tunnels, the FlipCutter will really grab a lot of graft each time and just deliver it into the joint very, very nicely. I'll switch back and we can upsize now to a seven. And then back in. So now you can see we've got some more graph there. So I'm just going to remove that. So we'll then just remove the graft off of here like this. Quite easy. Sometimes the graph will get sort of stuck there. So you just have to sometimes even open it up a little bit so you can get it out. We can get it back down to a size that we want. And then what I would say I'll switch back. And now we're going to take care to maintain our angle. So we're going to maybe kind of keep our hand raised just a little bit so that we maintain our old tunnel. And then we can open this up to eight or a nine. Good. And then we can go back in and start removing more of this graft. The original graph size was nine. So now we've got all that suture, all that graft on the FlipCutter. And what we'll do now is we'll go in and we'll just pull it off. There's a little bit of graft left in here. Again, this is a little bit of a different situation Because this graft isn't healed in place. And so a little bit more of it staying. But in general we've got good walls here. And you can bring the FlipCutter back in. And now you can, just like if you go in the center of it, you can just sort of expand that up to maybe a ten at this point and see what, what you can get, but you can see how a lot of it just pushes out there. So it's a lot of it's been released. So now you can see we've effectively got all the graft cleaned out. And now we can sort of see what diameter tunnel we have to work with here. So we can sort of just open this up and you can even just sort of spin it by hand and we can see what that what that looks like there. And we have it open currently to ten. So we could easily accommodate ten millimeter graft in here. And you can see it's not too big. We could easily do a single stage revision on this. We can comfortably now go harvest a quad tendon. And then we'll just keep this tunnel established so that we can come back if we need to, and adjust the size of the tunnel with the FlipCutter three after graft harvest. But this is a is a good step to remount the graft first with this, to make sure that we can do this in a single stage, as opposed to having a tunnel that's too wide and need to do this in two stages. And you'd hate to harvest a graft and then not be able to use it. This is a nice little trick. Here is you can just use the red sheath or the red cannula from the FiberStick and use that as a placeholder. So you can put the drill sleeve back over this. This doesn't need to have a suture loaded up on it. And you can leave it in the joint like this. Or if you want to, you can bring it out like that. And that way you know it's going to stay in place and not fall out. And you can go ahead and harvest your graft. We've got our graph prepared. We have an 11 millimeter QuadLink graft. And now we're going to go back in and finalize our tunnels. So you can see here we've brought the FiberStick Cannulas. We brought one through the tibia as well. And we have one through the femur. And you can see by doing this with this red cannula, you can reinsert the drill sleeve over the top of it and actually fits in. It'll find the tunnel quite nicely. And I'll just show you show you that real quick. If we look up here into the femoral tunnel, you can see it right there. You can find it quite nicely. Now, this is a little loose because it's a cadaver. So we're going to have to kind of mallet this in a little bit. But you can see this is a really nice way to preserve your entry point. So we'll just put that in a little bit more trying to get it. There we go. Yep. And we'll and we'll purposely take it over like this a little bit. That way we know we're firm in there and we can pull it back as we need to to adjust our tunnel, but that's going to be perfectly fine. So now we can pull that out just like that, and now we can come in with our FlipCutter and then we can open it up to an 11. Yeah. And if anything here we just have to make sure that we're, that we keep it centered because there will be a little bit of toggle at this point. So that's going to be the one thing where we have to be very mindful with our FlipCutter is keeping it centered. And so I'll just back it out a little bit. So open that up to an 11. And about right there looks looks quite Go ahead and push it back in. So and you can open it back up to an 11. And just make sure that we've and you can just kind of bring it to the aperture and spin it by hand. And just make sure that that looks okay. And just take that all the way around. And we'll kind of bring it up. Yeah. And if you want to just kind of just hold it like this, if you want to just kind of run it one more time, I'll hold the angle just like that. Yeah. Perfect. That's great. Good. And then we can just remove it and we can place a regular FiberStick in there that's in. You can see that's a nice tunnel that we got there, got the maintained a back wall, but we opened it up to an 11. All the graft is out 360 bone throughout. It's back far enough okay let me switch. I'll go in there and I'll and I'll switch portals. You can take the drill sleeve out and we'll luggage tag those sutures. Get them up out of the way, and then we can basically do the same thing on the tibial side. So we've you can see we've already cleaned our tibial side out. And so now we'll get the drill sleeve back and then we'll just ream that up with the FlipCutter. And then I'll kind of just hold this in place right here. Because of the demonstration table, we'll have to kind of position the knee appropriately and we'll open that up to 11 and then just kind of yeah. And then we'll kind of bring it back and then and just kind of that looks like that's pretty well centered. Yeah. Perfect. And we'll pull that back and up and back. And it looks like we've got that tunnel where it needs to be. And there we have it. So now we have a standard all inside. Reconstruction technique with our passing sutures, and we've got our 360 degree cleaned out tunnels on either side just like this. And we can still maintain an all inside technique. The adjustable loop cortical fixation on both sides. So it's optional a lot of the times the graphs will fit through this passport cannula. But some of these quad graphs get so big that they do have a harder time passing. So once I've got my passing stitches, I will often take this out and then have them like this. It just makes the passage just a little bit easier. If you've got a bigger graft, if you've got a small graft, like an eight millimeter graft, then this is no problem. But if you've got something like we've got here, which is 11mm, then sometimes it's easier if you take the passport out. So now we're going to just pass this graft as we typically would. So we're going to pass it through the femur. We'll deliver the button out of the femoral tunnel. Yeah. And then we can just pull it down into the tibia just like that. And here we've got a beautiful, just huge quadricep tendon revision ACL reconstruction here. And then we can attach an ABS button. And if you want to you can also put an internal brace on this. I usually load it up through the TightRope PT button. And then you can fix it on the tibia with an independent swivel lock. Now we can watch it tension intra-articular and we can retension the femoral side. And there you can see just excellent tension on this graft. And so here we have a revised ACL in an all-inside technique with fantastic tension on it with a using the FlipCutter three and a QuadLink graft using the FiberTag TightRope. And you can see that it's quite minimally invasive. And we're able to do all graft removal and tunnel creation using an all-inside technique.

Revision ACL Reconstruction Using the FlipCutter® III Drill

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