Name: Flexible TightRope® Drill Pin and Reamer for ACL Reconstruction With ACL TightRope Implant
Uploaded: 2018-03-05T00:00:00Z
Channel: Arthrex
Description: Asheesh Bedi, MD, (Ann Arbor, MI) demonstrates the flexible TightRope ® drill pin and reamer for anterior cruciate ligament (ACL) reconstruction using ACL TightRope fixation.

<p>Asheesh Bedi, MD, (Ann Arbor, MI) demonstrates the flexible TightRope<sup>®</sup> drill pin and reamer for anterior cruciate ligament (ACL) reconstruction using ACL TightRope fixation.</p>

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VID1-01281-EN | C | Flexible TightRope® Drill Pin and Reamer for ACL Reconstruction With ACL TightRope Implant

Asheesh Bedi

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Flexible TightRope® Drill Pin and Reamer for ACL Reconstruction With ACL TightRope Implant

Today we get the opportunity to demonstrate the flexible reamer and guide pin system. As you can see, when you get your kit for the flexible reamer, it will come with a TightRope pin. Some advantages to this TightRope pin just to feature here one. It has the typical flexibility of your flexible reamer pin, but one large advantage is it has this enlargened head and tip that serves as a dual purpose for actually reaming the tunnel for your TightRope. In addition to the TightRope pin together with the kit, you get your flexible reamer. These are disposable one time use reamers, which certainly offer tremendous advantages. They're sharp every time for single use, which certainly is advantageous in preparing the socket and minimizing any risk of of metallic debris or fracture. As you can see, they're marked here to allow preparation of a socket to correlate with the measurements that you've obtained from your TightRope pin. They offer tremendous flexibility, as you can see here a good tone at the junction, but here allow you to navigate around the tight corners of a narrow or a frame notch, and also minimizing risk of iatrogenic injury. In that regard, being forgiving of a variety of different medial portals. In the past, we've talked about our guide that you can use to advance this TightRope pin. It's retrograde loaded into the guide in this fashion, such that the enlargement head is ready to go in your previously marked spot at the center of your footprint. And again, this variable angle that allows you to pick the trajectory to your optimal obliquity in the coronal and sagittal planes. So one of the simplest steps that can happen your scrub nurse or you yourself can load the pin. It's done rather easily. Here you have this sort of pin gripping tool here provided by Arthrex. You can see how this works. You take the back end of the pin, which also has the eyelet later for your shuttle suture, and it's passed here through through the the pin holder device here. And this is retrograde loaded into your femoral guide here you can see this is advanced through one of the more difficult spots to navigate is just the curve of the guide, which is why that's retrograde past. You simply continue to use this just like you would a key or gripper, and you can see that pin emerges on the back side of the guide here. Once you have a sufficient amount here at the back of the guide, you can simply pull the pin back flush to the guide. It's important that we load that and seat that. Head down into the guide so that we still have the sharp tip of the guide exposed to engage the center of our previously marked point on the wall of the femur. So as you can see there, the head seats and is somewhat recessed in the base of the guide. As you can see, after you have your pin loaded here, there is some curve that is introduced into the pin as you feed it through. But as you can see, this pin has tremendous malleability. It's a little bit of a small technical pearl that if you straighten that pin out to a degree, it will just make it easier for your assistant or for yourself when you load the reamer over the pin after you've engaged it in our in our ready to proceed with socket preparation. As we shift gears here now to to look inside the knee joint, you can see here this is a view actually, from our medial portal. We've prepared this specimen to have removed the ACL. You can see here a little bit of preparation on the tibial side for our footprint preparation here on the femoral side you can see we've left the residual fibers of the footprint here our anteromedial and posterolateral bundle here you can see here we've made our previously marked location here. It's just slightly above the footprint. Again we've put that in that position so that when we ream we don't get too low on the wall, but that we capture the fibers of the footprint that allows us to shift our camera now laterally. So we're in a good position and we can see our previously marked spot at that location just centered around the footprint. This now allows us to introduce our guide through the medial portal. Here you can see how that comes in, as we've previously marked that location that makes this very easy to align our Pin and our pin guide to engage the lateral lateral wall and make sure that we're centering the head of that pin right in our previously marked and desired location for footprint preparation. As you can see, I can adjust my hand here to change the change the obliquity of the guide. Again, looking at the outside and the inside of the knee to get the desired coronal and sagittal obliquity, I'd like for the femoral socket at this time, with the guide engaged, we can simply advance that guide pin into place. By just dropping my hand, I'm able to introduce a little gentle flexion into the knee joint. And you can control that. As you can see yourself just by the amount of pressure that's applied to the to the guide. A couple of technical pearls. Because this is an enlarged head pin, you want to allow the pin to do some of the work and and spin before it engages the the wall. So a good technique is to use full speed and power, but not to provide a forceful advancement. And as the pin begins to advance through the cortex, just gentle pressure until you advance to the outer cortex. The same way when you get to the outer cortex, just gentle pressure so that the pin doesn't escape and escape out into the iliotibial band and soft tissue. At this point, we're just going to gently advance the pin. Here. You'll see this here it advances easily and nicely to the outer cortex, and then right up to the outer cortex and just and just past. You can see there is a marked laser line on the pin. This is to be helpful. As you know, on the end of the pin is an eyelet, which you're going to use to ultimately load your shuttle stitches. If you grab this past this laser line, it can squeeze down the eyelet and make it difficult to load your shuttle stitches later on, as you see here. Now we can remove the guide again on flex the pin to a degree that will help you when you pass your reamer. So as you can see, once your pin is advanced here, the enlarged head gives you the advantage of using it. Also as the measurement tool. Here I can gently pull back and feel the hard stop at the base of the tunnel. This is where the pin head is now engaging the outer lateral cortex. In this case, you can see that this overall tunnel length is about 35mm, which leaves us plenty of cortical bridge for preparation of our femoral socket. This obviates the needs of previous systems, in which you'd have to place a depth guide to measure the overall length of your tunnel. And again, because of the enlarged head, We've already prepared the track for our TightRope. Now we simply need to use the flexible reamer to complete our femoral socket. Once you've completed your your measurement on the inside, it's now useful to go ahead and advance your pin outside of the skin. You can simply advance that with a little bit of pressure and force. You'll see where it tense the skin there. It's usually a helpful trick to make a small nick in the skin before you advance that pin through, because it has the enlarged head it can otherwise walk subcutaneously, but here you can see the pin head. At this point, I usually pass this through and even engage it with a snap or a Kocher just to keep that fixed. So a couple of pearls. Now for advancing your reamer over the pin. Step one here is make sure that you take all of the flexible links and advance them past the end of your wire, such that the rigid portion of the reamer is already all over the wire. You can see this makes it very easy to get a sense of the trajectory as this slides along the pin. If you're looking on the screen and not paying attention to that and applying force, the reamer is very forgiving and will simply bend and bend and flex with the pin. So that's usually step one, as you can see on the screen. Step two as an additional safety is to turn the eyes of the camera back on the medial portal to assure that you're protecting the medial femoral condyle as you advance. As you can see here, there's only one cutting tine on the reamer here that induces an additional margin of safety such that when you introduce the reamer, you can keep it facing north or away from the condyle, such that as you advance and shift the reamer through the cutting, tine is always facing the notch. So here as we bring this through lots of different ways, but usually I'll bring it close to the soft tissue here and simply advance that. As you can see, with the gentle back and forth motion into and through the fat pad of the knee. And again, with the cutting tine facing us, it's always keeping it protected from the medial femoral condyle. The same technique can then be utilized to pass right by your PCL, keeping the cutting tine away from the PCL. And now we're prepared to to to ream our socket. Having protected the soft tissues here, we're up against the wall in wall in gentle hyperflexion the reamer simply follows the pin. Again, I advise not using a lot of pressure with this reamer, which will only bend the pin. They're very sharp and so they will cut quite aggressively. Here we'll go ahead and start the reaming process here. We know that we want to prepare an approximately 25 to 30 millimeter socket on forward. You'll see these lines are easy to read as we advance there. We can periodically stop there. We're at about 18. The next line there is approximately 24. And remember, because of the obliquity of your socket, 24 anteriorly is likely about 20 posteriorly. You can see here at about 28 anteriorly we're probably about a 25 millimeter socket. So I usually advance right up to close to that point. And again remember from our overall length we know we have a good cortical bridge. It's a good idea to clear your debris at this time. That's because you're passing. Suture is not in the knee and you're not vulnerable to capturing it with your shaver. So it's a good point at this time to go ahead and clean any of the bony debris with your shaver or suction. This is also a good time to confirm that you've preserved the back wall, and that you're happy overall with the capture of your footprint and your aperture geometry. As you can see here, we'll clear all this debris away before we go ahead now and load our passing stitch, which will be ready for our for our femoral side of the GraftLink. Here you can see we simply pull that loop through. We keep the loop end towards us to later dock our TightRope stitches for the GraftLink, and we can be more critical of our socket looking from the medial portal here. I think here we have nice aperture geometry capturing the bundle. Still a preserved 2 to 3 millimeter back wall, and sufficient depth with our well prepared and centered exit hole for our TightRope preserving a good lateral bridge for fixation. Yep. Perfect. So as you can see at this step, we've now gone ahead and prepared our femoral socket as well as our tibial socket using a FlipCutter. At this step, it's important to grab the suture that comes out from your FiberStick. I tend to also grab our femoral stitches at the same time, so that we shuttle them out and assure that there's no tissue bridge through our medial portal when we bring in our GraftLink. So as you can see here, you can certainly use a passport cannula as well to avoid a bridge or a shuttle. Both stitches out together there. We're now in a good position to go ahead and load our our GraftLink through the medial portal and begin to plan docking on the femoral side. So you can see here we have our prepared GraftLink. This is our compression tool that allows us to perfectly size that and and contour the graft for, for docking with our preloaded TightRope on the femoral side at this step. Now we'll go ahead and we're prepared to go ahead and introduce the graft. We'll use our shuttle stitch on the on the femoral side to go ahead and pull the sutures for our TightRope through. It's been my preference and a technical pearl to sometimes view the button going up your femoral tunnel from the medial portal. A simple way to do that is to advance your blue stitches or your lead stitches, and to take up slack with your white stitches as you're advancing from the femoral side. As you can see here, we can follow the button going right up the socket here as we're just emerging outside of our lateral cortex of the femur. You'll you'll see the button begin to flip there. At that point we know that we're just flipped outside of the wall, but not too far past our iliotibial band. And you can demonstrate there that we're fully flipped on the femur and seated, and we're now we're in a good position to go ahead and begin to cinch our graft up. At this point, you shift the camera back to the lateral portal here with our white stitches. We'll cinch back and forth and begin to shuttle and seat the GraftLink in position. Again, the GraftLink has been marked so that we know when we've seeded close to approximately 20 to 25mm of graft that occurs when those sutures disappear. Now we're in good position to in a standard fashion, go ahead and plan for retrograde seeding of our tibial socket. The sutures are shuttled down through the tibial side, and the luggage tag stitch is removed from the TightRope to allow for a seeding over the concave ABS button. Here you can see we're going ahead and seeding the concave ABS button down on the proximal tibia. We would do this typically in near terminal extension or terminal extension here. Here's your finalized construct with anatomic sockets prepared with the flexible reamer and the FlipCutter seen here from the medial portal. You can appreciate the nice obliquity both in the sagittal and the coronal plane. And again our overall anatomic construct with an all-inside GraftLink using the TightRope pin and flexible reamer system.

Flexible TightRope® Drill Pin and Reamer for ACL Reconstruction With ACL TightRope Implant

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