Name: Posterolateral Corner with ALL Reconstruction Using SpeedGraft® Presutured Tendon and Arthrex Amnion™ Matrix
Uploaded: 2017-12-19T00:00:00Z
Channel: Arthrex
Description: Babak Samimi, MD, (Los Angeles, CA) demonstrates a posterolateral corner reconstruction with an ALL reconstruction using the SpeedGraft ® presutured allograft tendon with SwiveLock ® anchor and TightRope ® fixation. Dr. Samimi also demonstrates wrapping the peroneal nerve with Arthrex Amnion™ matrix to help prevent adhesions and scarring.

Babak Samimi, MD, (Los Angeles, CA) demonstrates a posterolateral corner reconstruction with an ALL reconstruction using the SpeedGraft® presutured allograft tendon with SwiveLock® anchor and TightRope® fixation. Dr. Samimi also demonstrates wrapping the peroneal nerve with Arthrex Amnion™ matrix to help prevent adhesions and scarring.

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VID1-01109-EN | A | Posterolateral Corner with ALL Reconstruction Using SpeedGraft® Presutured Tendon and Arthrex Amnion™ Matrix

Babak Samimi

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

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

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Posterolateral Corner with ALL Reconstruction Using SpeedGraft® Presutured Tendon and Arthrex Amnion™ Matrix

Hi. Bob Tamimi here talking about posterolateral corner reconstruction with allograft plus al reconstruction. This is a complex injury and there's different treatment options for this. However, my goal was to create a hopefully more simplified procedure of using a single long graft. This is a SpeedGraft. This graft measures about 300mm. Plus using a combination of SwiveLock anchors and ABS, TightRope and a button. Okay. I like to start off by marking some of the anatomy. Here's the fibular head and neck. And here is our lateral epicondyle. This is Gerdy's tubercle over here. And our incision. Is going to come. Along this dimension, and for demonstration purposes today, we're going to make our incision large enough so we can adequately see for the first order of business is to find our perineal nerve and identify it and retract it and get it out of harm's way. Frequently in these injuries, due to the nature of the trauma and usually a multi-leg situation, there can be considerable injury to the perineal nerve and frequently peroneal nerve palsy and stretch or traumatic injury to the nerve. And so frequently what I like to do is identify it. And what I found in my practice to help is to use a amnion to help minimize post-traumatic scar tissue around the nerve, and to help promote its healing. Now, commonly, you can feel the nerve right here, just under your finger across the fibular neck. And here we can see the nerve so frequently this will be scarred down to the adjacent tissue, and there will be some scar. And one can free up this nerve. So here's our peroneal nerve. Okay. So once we've done that, now we can look at our bony landmarks. I like to come over and identify. We have here our fibular head and neck. Here's our gerdy's tubercle. Here's our lateral epicondyle. Here's our fibular head and neck and here's gerdy's tubercle. I go ahead and make an incision here. We're going to go across this IT band and get down. And I can actually see here some of the bands of the ligament now. So we can feel the anterior portion of the joint line. Take the knee through range of motion and identify our position adequately. So we've previously sized our graft to a size six. And what we're going to do is use a 2.4 cannulated pin. Which will then allow for us to insert our six millimeter cannulated drill. To about a depth of 25. So now we've got our graft and it's going to come in here. You can see the graft going into the socket. I'll go ahead and advance our bio composite screw. Make sure it's down here. We also have our second femoral socket position. We can go ahead and drill that now in preparation. Since we have it exposed this one is just a little bit more proximal. Because we're putting the folded over diameter this one we've measured it to a size seven. Now we're going to go ahead and complete our dissection here for the fibula. We all again have to be very cautious of our nerve. But now that it's nicely retracted out of the way. So we just want to nicely expose the fibular attachment sites of the fibular collateral ligament that we're going to reconstruct. And then the popliteal fibular ligament which you can see appears to be this here that I've detached. Now using the same approach we will again cautious of the nerve will allow for us to dissect here and now. This back here is the posterolateral aspect of the tibia that is going to allow for us to reconstruct our popliteus and our fibular ligaments. We've got this nice and exposed, and our nerve is very far out of our way and it's not in harm. We're going to go ahead and wrap this fibular guide in advance. So we're going to go ahead and drill the fibular. We're going to leave that there. We back that up good. And now we're going to go ahead and drill the six again. So we're going to go ahead and pass this FiberStick to facilitate passage of our graft and grab this suture here. So now we have our fibular tunnel prepared okay. Now we can change our guide to the tibial guide. And we've already got this exposed here I can see the back of that posterolateral tibia there where our popliteus tendon crossing here. And we can adjust this so we avoid tibial tuberosity. Go ahead and mark that and make our Acre incision. What's going to happen is this will loop down into the tibia. The other end will come out the fibula. Here, jack it back up to this, and then from here. So now we have our tibial guide with a stepped obturator. And this is going to come right back over here, just behind the fibula along that posterolateral tibia. And you want to feel the joint line right here. And just want to make sure you're just underneath that about a centimeter or so. Caution is taken to avoid the tibial tuberosity. A little incision is made here. And the anteromedial surface. Now we're going to use a FlipCutter. And we've measured the folded over diameter of this graft to be eight millimeters. So we're utilizing an eight millimeter FlipCutter here. And I'm going to come all the way across here. Great. I felt that far. Cortex. Then what I'm going to do is slide this obturator back, remove the guide while keeping our Protector in place at all times. Now we can see our FlipCutter having come through. So then we're going to go ahead and. Make sure it's adequately passed across the cortex so we can flip the FlipCutter. And now that that's adequately flipped we can go ahead and use a mallet to advance our obturator. That way we can come all the way out to the far cortex if necessary. And full speed, slow, gradual. And we've now maxed it out at our obturator. We come on back and we can go ahead and flip it and remove it. Next we're going to pass up a FiberStick or a FiberSnare would work just as well. This will allow passage of our graft. So now we can take our abs TightRope. And we're going to use our graft now graft to loop through the TightRope. And we can advance it to the back of the knee. Let's have a suture to prevent premature tensioning of this TightRope. We're going to go ahead and now feed our ReadiGraft through the back of the tibia coming forward. And then here comes our whole construct. We successfully passed it. We want a little bit of this graph to go inside like that. And you only need about 15mm of the graph. Now I can tension this. And you can see that that brings the folded over portion of the graft across. We're going to go ahead and pass the graph from posterior to anterior. Through the fibula. You've got your tension here and you've got your tension here. So that's what's creating the popliteal fibular ligament and the popliteus. And then this comes across to create the fibular collateral ligament. The nice thing is that we can do some final tensioning later. We can get some provisional tensioning now and then we can complete it later. So now we're going to fix our abs button. We're going to hold a little bit of counter tension on that. And just tension a little bit at a time. And so we're going to allow that button to slide in under the skin and seat nicely without any soft tissue. Bridge interposed on the cortex. Now, here I could just provisionally tension that. We're going to go ahead and take our fork. Tip SwiveLock just clear some of this soft tissue out of the way once I get my tension across here. That's really to help stabilize the micro motion is really the only purpose that it's for. So I can go ahead and complete my construct. So this is going to come across. So now we're going to mark it where we want the graft to come in. And then about 20mm proximal to that. Okay. So then we're going to go ahead and insert the graft into our socket. And we want to make sure our tension is good. And we could adjust each of these tensions if we want. And I could still continue to tension on my tibial side as well. So now this is our posterolateral corner. You can see here we've got it wrapped around for the fibular ligament, the popliteus and the fibular collateral ligament all using the one graft. And here I could still do my final tensioning on the tibial side at the desired flexion extension. And you can see the as the isometry changes with the anterior and posterior portions. When you go from flexion to extension you can see that happening. And here I can continue now to tension. Additionally my construct there you can see that tightening as desired until one gets the appropriate amount of tension. I do like to prevent micro motion here at the at the fibula and prevent loosening and fracture here. So what I will do is I'll go ahead and put another screw. So now we can go ahead and and advance an additional screw here. Good. And we want to make sure it's not proud on the posterior side. So now we're going to come down here into the insertion. Trim the graft to the appropriate size to allow for dunking of the end of the graft into the prepared socket at the At the appropriate tension, and we've sized it to a size six. We're going to go ahead and drill. All right. So now we're going to go ahead and advance the graft. Now we can go ahead and advance our graft into the prepared socket. Make sure we like our tension. We remove our stay stitch. Now we can go ahead and cut our sutures. So now we've reconstructed our posterolateral corner with the LCL popliteus fibular ligament. And we've done the all all to help reconstruct that whole posterolateral corner and that lateral aspect of the knee. The advantage here at this point is taking the knee through range of motion. I still am not stuck, and I can still additionally tension my graft here with my sutures as needed to the appropriate tension, and to check isometry and range of motion throughout the procedure. So at this point in time, I would like to go ahead and address our Address our peroneal nerve. Here we have it dissected and released. And so what I'd like to do is wrap this amnion tissue around our nerve to help protect it, to help prevent scarring, and to help recovery in the circumstance of a nerve injury. So now we're going to go ahead and wrap our amnion tissue. You can see here the amnion coming across. And I like to lay it on the nerve. Now we're going to go ahead and wrap it circumferentially. And there we have it allowing it to be protected. I would obviously irrigate the wound prior to applying this amnion tissue, as you don't want to irrigate afterwards and then close in layers as appropriately. Thank you.

Posterolateral Corner with ALL Reconstruction Using SpeedGraft® Presutured Tendon and Arthrex Amnion™ Matrix

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