Name: ACL GraftLink® Technique Using the InternalBrace™ Procedure
Uploaded: 2018-05-16T00:00:00Z
Channel: Arthrex

Patrick A. Smith, MD (Naples, FL), demonstrates the GraftLink® technique using the InternalBrace™ procedure. Dr. Smith explains how to properly load the ACL TightRope® RT implant with FiberTape® suture for the InternalBrace technique.
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.

Not Hidden

English  - en

video

VID1-00375-en-US | B | ACL GraftLink® Technique Using the InternalBrace™ Procedure

Patrick A. Smith

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.

Operationstechnikvideos

Surgical Technique Videos

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

Vídeos de técnicas cirúrgicas

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

Videos de técnicas quirúrgicas

ACL GraftLink® Technique Using the InternalBrace™ Procedure

The first thing we need to do is load our long FiberTape seen here through our button. And for the independent InternalBrace, we're going to use the double loaded TightRope as seen here, which has the number two TigerWire passing suture. And there's also a number five through this second hole here to pass the FiberTape. We're first going to remove the number five suture. So now what we're going to do is we're going to pass the stiff end of the FiberTape through this hole alongside our mechanism. So conveniently the FiberTape has a stiff waxed end. And so we can pass it through Alongside as seen here. So we want to make sure that there's two passes through the button with the FiberTape. And we want to make sure that we have it oriented properly, so that the two free ends of the tape are going to be on the tibial side. We take the other stiff end, which is much easier through the vacated hole from the passing suture that we removed. Then we're going to even out the tapes. So now we have our independent InternalBrace passed through the femoral suspensory TightRope fixation button. And the free ends will be on the tibial side here. Now we prepare the graft. We've created our four stranded GraftLink construct. And before we're going to do the suturing, we want to go through this important step of how to pass the tapes. And when done this way, upon completion, the tapes will be inside the construct. It will not be visible at the end of the procedure when the graft is in place in the knee, which is nice. We have four strands of the graft. So if you take a hemostat and come between the outer on one side and the inner construct and pass one end of the tape as seen here, and the same thing on the other side through the outer limb of the tendon, from the central part of the tendon, pass the other side, and then we'll put our linking sutures on each side. The tapes will still slide as we'll show you. And then upon completion of the construct, the tapes will be within the middle of the graft. So we have our two cerclage sutures on the femoral and tibial side. And you can see the internal brace as I pull it slides easily. So even though we have the the linking sutures, it does not grab the internal brace so it stays totally independent of the graft, which is critical. So we're going to drill the FlipCutter. So there we are. Take the six over nine guide out. So the first step here is to pound the guide sleeve down. You can see the ten millimeter FlipCutter. Then we'll pass our FiberStick. Just use a simple loop grasper to retrieve that. For our passing suture. Then we'll dock this. So our FlipCutter comes out directly where we wanted it to in the ACL footprint. So we'll RetroCutter our tibial socket. To shave her in place. That debris out. So now we're going to pass through our TigerStick. Here's our loop Grasper. So this will be our shuttle suture on the tibial side. So now we're going to pass our graft. We have to retrieve our docking suture from the femoral socket. Having the passport cannula in place makes this very easy now. So here's our femoral docking suture. That's out the passport cannula with our tibial suture. What I'm showing here is a nice trick to allow for easy passage of your button on the femoral side, so you don't have to use X-ray intraoperatively. So we know our intraosseous distance we measured when we created our femoral socket was 40. So what we're doing is just marking our strands at 40, but it's from the distal end of the button. Because remember, what's going to happen is the button is going to go out the small femoral hole. And we expect it to flip on itself at 40mm from the end of the button, which would be the aperture, the hole on the femoral side. So when we see those blue marks pass into the femoral socket, we know the button will be outside on the femur and it will flip easily. And it's right on the bone. And it's a nice way to do it without having to use x ray. Intraoperatively. So first thing we do is we pull those four sutures out the femoral side, and then I'll put the scope back into the joint. We'll watch the button pass. And here's the button. You can see the FiberTape pass through the button as we did initially. And we're going to look for that little blue mark where we measure the interosseous distance where we expect the button to flip on its own. So it's a little bit under the tapes. There. There it is. So you can see our blue mark coming through the passport cannula with the graft. There's the blue marks. So Right right there. That point, the button just flipped right the aperture there at our 40. So we pull back, you can see we've got we've got our fixation now. Now a key point right here is I like to pull the slack out of the tapes. So now we're going to hoist the graft up into the femoral socket with the TightRope T shortening strands on the femoral side. It's important to keep some degree of tension on the tapes just so there's no slack of the independent InternalBrace. So we've marked the graft. Graft was 63 long. So we're going to pull it up 20 into the femoral socket with our intra-articular measurement of 23. So there's our graph going up into the femur. We'll go to the blue line right there. Perfect. And then we'll pass the tibial end of the graft with the no button loop into the tibia. And we took the slack out of the tapes. So the next step is going into the tibia. Another important point here is you never pass the loop alone? We always put a shuttle suture to protect the loop. So we're going to pass the two ends of the tape and the shuttle suture for the TightRope. No button loop into the tibia. So now we deliver the two tapes and then we'll deliver the TightRope. No button loop out the tibia and then the graph will pass. There's our graph going into our tibial socket. We'll pull that down. And you can see we're right pretty much on our numbers 23 Intra-articular distance. There's our graft in good position. And so now we can address the tibial side. First thing we'll do is we're going to take out our little passing loop for the no button TightRope. So that number two we just pull that off now. So now we're going to apply our button the ABS button to the no button loop. So attachable button system. This is a 14 millimeter diameter button. It's perfect for the independent internal brace because there are two accessory holes in the button to allow separate passage of the tapes through the button. So we're going to come in first and apply the apply the shortening strands on each end of our ABS button. So now what I'd like to do is I like to shorten the shortening strands here a bit on the tibia. So I'm just going to take some of the slack out of the system. I'm not tightening it all the way. I bring it down to about here. So now we're going to pass the independent InternalBrace tapes. So what I'm going to do is pass one tape for the independent InternalBrace through the one buttonhole. And then the other tape through the other hole. So now I have the tapes passed a huge point here is everything we're going to do with fixation of the independent InternalBrace. And the graft is at full extension or hyperextension if they have it. What I'm going to first do is just I'm going to bring the shortening strands down. I'm not tightening the tibial fixation. I just want to bring the button down to the tibia. And and that little nub fits in that hole. I just pushed it in like that. So I've not put any tension on the shortening strands at all. The reason is because it's going to be independent fixation. I'm going to first fix the tape ends for the internal brace and then we'll fix the tibia. Finally with the shortening strands. The important point right now is to make sure all the slack is taken out on the table side. For my fixation of the two tape ends, we use a 4.75mm biocomposite SwiveLock. And so we have a step drill to make a 4 or 5 hole. And generally I'm about a centimeter or so distal to the button. And you can see our button right there. So come in with the drill just about a centimeter or so here on the tibia. And I drill the step drill down like so. You always have to tap the tibia. This bone is hard. So even in this cadaver it's not bad. So we tap that and then we're going to get our fixation for the independent internal brace. Race, we're absolute full extension. I've already taken the slack out of the tapes. One thing that's helpful here is you don't want the tapes to be too tight. You can add a little hemostat here if you want to, to put a millimeter of slack before you fix the tapes. But actually, because they kind of come over the button, there's almost a millimeter of slack built in that way. So now again, we're in full hyperextension of the knee. I find my hole right there. Remember this is the independent internal brace. So we take this right to the cortex. Undo our sutures, and we can just check, make sure we're deep enough. Back this up clockwise. Looks like I'm perfect right at the cortex. Vortex. So at this point, I do not need this suture that was in the SwiveLock the tapes are fixed. I can cut the tapes. Internalbrace is done. Now we need to fix the graph because I haven't fully tightened the tibia. I'd like to use the tensioning handles because you can get additional strength. So. Plus it really is a lot easier on your fingers. And now what I like to do is cycle the knee. And I'm pretty vigorous at this step where I really want to take this knee through a range of motion 25, 30 times. Put on the graph, put a little draw. Lockman on the graft. Any creep I'm going to get out of the system. So I think this is really important because what I'm going to do, and this is the advantage of the all-inside technique with suspensory fixation on the femur and tibia, I can retention. So I can take out any slack in the system that might happen here just from ranging the knee. So I really put some force on it here. Lockman Pivot, do it. Intraoperatively. So now, once I've done that, we go back into our fully extended position. We're going to take out our passing suture for the femoral button because we know we're in good position on the femur. We're going to apply the tensioning handles now to the femur. And just as we did on the tibia, again, keeping the knee fully extended or hyper extended, we're going to retension. So if there was any creep in the system just from doing that vigorous range of motion, we can take it up at this point. Once we do that, I come back to the tibia and I do one last time on the tibia. So this is my sequence. First fix the two tape ends for the internal brace full extension with the swivel lock. Then I do my preliminary tibial fixation with the handles, cycle the knee vigorously, and then do the femur again in full extension or hyper extension and the tibia one more time. And then since the sutures are right here, I go ahead and tie these to my button because this does give me some backup fixation. Remember, I showed you my buttons right on the bone. And so I just go ahead and tie my no button sutures here. Down to the button here. Just give me a little additional fixation. I've never had to take a button out. These are low profile. So that's the completed all-inside technique with the independent internal brace. And we'll take a look at our graft. So here's our final construct. And you can see the quadruple semitendinosus. Notice you don't see the tapes for the internal brace the way I showed you the graph preparation. The tapes are inside. Got great tension on this graft and bundle attachment. Femur tibia. Isometric tapes in place. Very secure. Good position of the graft. Remember I only use the semitendinosus, so I preserve the gracilis. Another advantage of this technique all-inside. You just need the semi only to quadruple. For the purposes of this demonstration, I'm going to dig into the graft a bit to find the tapes, because I want to show you that there is going to be laxity of the of the tapes inflection. The normal ACL goes through a loosening pattern from 0 to 90 of three millimeters. So the tape was fixed in full extension where it would be the tightest. But it's going to be lax in flexion. So I'm going to bring my probe in. And I'm going to open up this graph a little bit see if we can find the tape. Here's one of the tapes. And you can see right here look at the laxity of the tape. We're at 90 degrees of flexion. You can see the tape. It's not too tight. The tape is an internal brace. We want the graph to see load. The tape is only going to kick in at a high load where there could be a stress to retear the graph. That's where we want the tape to protect the graph. We want the graph to remodel and revascularize and it will do that at the lower loads. So that gets really important point. Here you can see nine degrees of flexion. The tape has laxity. But again it's right within the graft. So it really looks nice at the end.