Name: ACL RetroConstruction™ System: A Decade of Experience and Outcomes
Uploaded: 2016-02-23T00:00:00Z
Channel: Arthrex
Description: William Garrett Jr, MD, PhD, (Durham, NC) discusses the history of the ACL RetroConstruction™ system and what he has learned since first using the system more than 10 years ago. He reviews the surgical technique, pearls, and best practices as supported by his biomechanical and clinical outcomes studies.

<p>William Garrett Jr, MD, PhD, (Durham, NC) discusses the history of the ACL RetroConstruction™ system and what he has learned since first using the system more than 10 years ago. He reviews the surgical technique, pearls, and best practices as supported by his biomechanical and clinical outcomes studies.</p>

Not Hidden

English  - en

video

VPT1-00606-EN | B | ACL RetroConstruction™ System: A Decade of Experience and Outcomes

William Garrett Jr

Human

A video of a live presentation reviewing Arthrex products or techniques.

Video einer Live-Präsentation, die Arthrex Produkte oder Techniken überprüft.

Präsentationsvideos

Presentation Videos

Vídeo de apresentação ao vivo analisando produtos ou técnicas da Arthrex.

Apresentação vídeos

Video de presentación en vivo que revisa los productos o técnicas de Arthrex.

Video presentaciones

ACL RetroConstruction™ System: A Decade of Experience and Outcomes

When I started doing ACL reconstructions, the outside end technique was the preferred two incision technique. That seemed to work well, and from what I knew of anatomy, it seemed to get the graft in the appropriate location. When the transtibial technique came out, I never got the feeling that I could put the tunnel where I wanted it. So the reason we have stayed with the outside end now FlipCutter technique is it's easier. We're looking at the knee the way we're used to looking at it. We don't have to get in hyperflexion. We can get it in the normal position, unlike the transtibial. And unlike the medial, the medial portal, we are not in the alt in the high degree of knee flexion with the drill that we have to worry about in a reamer, that we have to worry about doing damage to the femoral condyle. So it's it's all so visual. And if you are, especially in an academic situation working with young residents, I think you can make them see everything perfectly aligned during the time that you're teaching and learning this technique. I think it's easier to learn. So the trick on finding the femoral tunnel is find that reference point. Find where the articular cartilage ends and the synovial reflection begins. And if if one marks from there straight distal in line with the femur. Now it's it's distal. But in the with the knee flexed 90 degrees it's coming from deep in the field to close to the arthroscope. So if you find that. That combination of. That's a starting point, and this is the direction you'll go straight through the middle of the ACL footprint. You see the footprint. And then you can easily put the graft, put the tunnel in the middle of the footprint. We took a series of cadavers and did transtibial drills and then did the outside end technique in comparison, and then stripped away all of the soft tissue and found out that the transtibial pen that you would use for making the tunnel did not even touch the ACL footprint. In other words, you're trying to put it in the correct position in a big footprint, but even the pen missed the center of the footprint. Now, once you put the reamer in there, of course there was some overlap, but at the same time the outside end technique was able to give put us very close to the anatomic center of the of the ACL footprint within a couple of millimeters. So we did that. It didn't seem quite believable at first, but then several other laboratories did the same thing, and it was clear that using the sort of standardly used transtibial techniques, one could not get it in the appropriate location. We then looked at people, subjects, patients who had had ACL surgery, either by the transtibial or the anatomic technique. So when we looked at patients, we used high resolution MRI and validated that with the cadaveric studies. And we found that the and and we used more than ten subjects who had transtibial or anatomic. And what we found is that the the same thing we found in the laboratory, the center of the tunnel, in the subjects who had transtibial ACL reconstruction. The center of the tunnel was outside the center of the normal footprint, and we also got MRIs of the opposite knee and were able to get the footprints. So the anatomic studies in patients and the cadaveric studies both showed the same thing, that we were much more precise with the anatomic or at the time we were using and still are using the outside in technique with either the RetroCutter or the FlipCutter. Now, does it make a difference whether it's outside in or transtibial? We had a technique developed primarily by Lou Dufresne in our lab that looked at in vivo kinematics of the knee by using high resolution MRI techniques of each side and getting simultaneous two dimensional flows so we can find out find out precisely where the bone is. And then if we map the MRIs onto the bone, we can find out exactly where the cartilage is contacting or where the relative positions of the femur and the tibia are. And using the same patients who had had either transtibial or anatomic ACL reconstructions, we found that the kinematics of the knee where the how the femur and the tibia are related to each other, were much more normal in the anatomically placed grafts. In fact, they were. There weren't statistical differences in translations and rotations between the anatomically placed grafts and the normal knee. The other knee, on the other hand, with the transtibial grafts, again, who were doing well, they were off. They were they even started off in, in extension in three degrees of three millimeters of anterior subluxation. What that means, you hope, is that you're going to end up with less arthritis and less degenerative change. And there actually have been other animal studies to point that out that dogs with partially transected ACLs versus completely transected. The more instability there is, the more arthritis there is in the long run. The next thing we we did was with that technique. We can see the cartilage thickness within less than a less than a 10th of a millimeter resolution. And we're finding differences in the cartilage thickness in the two different methods of reconstruction. We think that the cartilage thickness changes look better and they look more like the other side in the anatomically A group. There is a question now whether we're better off going back to old ways of doing things, because some of the European registries seem to be showing higher rates of retear in patients with more anatomically placed grafts. The European registries are done by a wide variety of surgeons, each with a relatively small number of cases. So there's nothing really very well controlled about how the cases are done. But I'm I wouldn't be at all surprised if a good study did not show that the that that is true. What you're trading it for is that the normal kinematics are worse in the non anatomically placed grafts. I don't I think I'd rather have a lifetime of good Kinematics rather than a little higher chance of repair. Plus divine intervention or 500 million years of evolution. Didn't put the ACL where it is because there was a better place to put it. You know, it's it just doesn't make sense to me to not restore anatomy the way that it was. There's also the question of fixed loop suspension or the TightRope. We had done a fixed loop for many years and then we switched to the TightRope. The fellow said maybe we ought to look them up. And my good idea was, yeah, yeah, go do that. So we had about 100 with the fixed loop and we had about 100 with the, the TightRope. And we didn't find any difference with CT 1000. And with the stability tests, radiographs, they were the same. And both both groups averaged about 1.5mm difference on the CT 1000, so they were both quite acceptable. I feel very confident that we can get an anatomic reconstruction with good biomechanics and good situation for biological healing with the RetroCutter, the FlipCutter, the suspensory fixation and the TightRope. Our failure rate is acceptable. The the CT 1000 are acceptable. We still have the problem. Grafts fail. People go back to sports. I think we have a much bigger problem now with rehab and biology of when to go back and how to recover. Then we have with surgical techniques, I think. I think our surgical techniques are pretty good right now. Excellent. Great.