All-Inside ACL RetroConstruction with Bone-Tendon-Bone Grafts Surgical Technique

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1 All-Inside ACL RetroConstruction with Bone-Tendon-Bone Grafts Surgical Technique All-Inside BTB ACL RetroConstruction

2 GRAFT PREPARATION 25 mm 25 mm 40 mm 5 mm 1 2 The overall length of the graft must be at least 5 mm shorter than the combined length of the femoral socket, intraarticular space and the tibial socket (1). In the example above, this total distance = 90 mm. This allows adequate space for tensioning of the graft (2). 20 mm mm mm 20 mm Trim bone blocks to a 20 mm length for an overall graft length of 85 mm or less. If the tendon length is over 45 mm long, it may be necessary to trim bone block shorter than 20 mm. The femoral bone block should be 10 mm in diameter. The tibial bone block should be tapered at the tip, approximately 8 mm, and increase to 9 mm near the tendon. Drill a 2.4 mm hole perpendicular to the cortex. Insert one #2 FiberWire through the femoral bone block. Through the tibial bone block place a #2 FiberWire and a #2 TigerWire through the drill hole.

3 PORTAL CREATION The lateral portal is placed in standard fashion along the lateral edge of the patellar tendon. The medial portal should be placed just medial to the patellar tendon and inferior to standard position to facilitate femoral socket preparation. Medial portal incisions may be oriented horizontally to allow instruments to be moved in the transverse plane. 3 FEMORAL SOCKET PREPARATION 4 5 Bring knee into 120 of hyperflexion and place the femoral aiming guide through the medial portal. Engage the posterior cortex with the guide and assure proper angulation before placing a beath pin. Proper angulation will assure preservation of the backwall and avoid backwall blow-out. After placing a beath pin, ream femoral socket to a 25 mm depth (for longer grafts, it might be necessary to ream deeper to accommodate the graft length). Use a beath pin to pass a graft passing suture and dock the suture in the femoral socket for later use during graft passing.

4 TIBIAL SOCKET PREPARATION 40 mm mm 50 mm Place a RetroCutter that is 1 mm larger than the tibial graft diameter onto the RetroConstruction Tibial Guide. Retrodrill the tibial socket as deep as possible without violating the distal cortex. Example: If the distance between the tibial plateau and distal tibial cortex is 50 mm, as read off the drill sleeve, then drill socket 40 mm deep. This will assure easy manipulation of the RetroScrew Driver and adequate space for graft tensioning. Clean the ACL stump off the anterior rim of the tibial socket using a shaver and/or OPES ablator. 8 9 Pass a looped Nitinol wire through the cannulated RetroDrill Pin and into the joint. Remove the RetroDrill Pin. Pass the RetroScrew Driver over the Nitinol wire and into the joint.

5 10 11 Angle the driver to dilate bone and create a path to the anterior edge of the socket. Remove the driver and use the looped Nitinol wire to pass suture into the knee and out the tibial tunnel (11). GRAFT PASSING Retrieve both the femoral and tibial graft passing sutures out of the medial portal. A cannula may be used to avoid tissue bridges. Using the tibial passing suture, tie a loop around a looped Nitinol wire. Place the graft sutures from the femoral end of the graft into the femoral passing suture. Load the tibial graft sutures into the tibial passing suture loop.

6 GRAFT FIXATION Pass the femoral end of the graft into place. Use the looped suture to pass the tibial graft sutures and wire into the tibia at the same time. Pass tibial bone block into place while maintaining wire anterior in the socket. Hyperflex the knee and fix the femoral side of the graft with an interference screw, through the medial portal Pass the RetroScrew Driver over the Nitinol wire and into the joint. Remove the Nitinol wire and replace it with a FiberStick. Retrieve the FiberStick out the medial portal through a Shoehorn Cannula. Attach the RetroScrew, 2 mm smaller than the socket diameter, to the FiberStick. Pass into the joint and load on the RetroScrew Driver. Cycle the knee while tensioning the graft. Keep tension on the graft while the screw is inserted into the tibial socket. A RetroScrew Tamp may be used to ease insertion of the screw. Backup fixation may be accomplished by tying the tibial graft passing sutures over a two-hole suture button on the anterior cortex with a sliding knot.

7 All-Inside ACL Reconstruction - Advantages Reduces patient morbidity Reduces or eliminates soft tissue hematoma formation Smaller incisions improve cosmesis May simplify rehabilitation Reduced infection risk Anatomic socket creation without transtibial drilling restrictions Distal cortex maintained for simple, low profile backup fixation Proven joint line fixation increases graft stiffness Maintains joint distention throughout the procedure Recommended Transitional Surgical Steps to Performing All-Inside Reconstruction Techniques A RetroDrill may be used to create a complete tibial tunnel and may be the preferred technique before moving on to the All-Inside ACL Reconstruction. The RetroScrew may also be used to fix the ACL grafts anatomically at the aperture of a full tibial tunnel. Step 1: Full tunnel retrodrilling Reduces fracturing of the tibial plateau as seen with standard tibial reamers Cuts cylindrical tunnels that are true to size Visualize tunnel diameter before drilling Constant Tibial Guide provides unparalleled accuracy Step 2: RetroScrew aperture fixation with full tunnel Anatomic, aperture fixation increases graft stiffness Strong cortical fixation at the tibial plateau Promotes graft incorporation by sealing off the tibial tunnel from synovial fluid

8 Ordering Information Instrumentation: RetroScrew Driver, thin RetroConstruction Marking Hook for Tibial ACLR, 52.5 RetroConstruction Guide Drill Sleeve, 3 mm RetroConstruction Drill Guide Handle Transportal ACL Guide (TPG), 4 mm Transportal ACL Guide (TPG), 5 mm Transportal ACL Guide (TPG), 6 mm Transportal ACL Guide (TPG), 7 mm Transportal ACL Guide (TPG), 8 mm Low Profile Reamers, 5 mm - 11 mm Button Inserter RetroScrew Tamp RetroScrew Tamp, 90 Tunnel Notcher Graft Passing Cannula, 11 mm Disposables: RetroCutters, 6 mm - 10 mm (in.5 increments) RetroCutter, 11 mm RetroCutter, 12 mm RetroDrill Guide Pin, 3 mm, cannulated (for RetroCutters) All-Inside Disposables Kit Implants: Tibial: RetroScrew, 7 mm x 20 mm RetroScrew, 8 mm x 20 mm RetroScrew, 9 mm x 20 mm RetroScrew, 10 mm x 20 mm BioComposite RetroScrew, 7 mm BioComposite RetroScrew, 8 mm BioComposite RetroScrew, 9 mm BioComposite RetroScrew, 10 mm Suture Button, 3.5 mm Suture Button, 12 mm round Femoral: Sheathed Bio-Interference Screw, 7 mm x 23 mm Sheathed Bio-Interference Screw, 8 mm x 23 mm Sheathed Bio-Interference Screw, 9 mm x 23 mm Sheathed Bio-Interference Screw, 10 mm x 23 mm BioComposite Interference Screw, 6 mm x 23 mm BioComposite Interference Screw, 7 mm x 23 mm BioComposite Interference Screw, 8 mm x 23 mm BioComposite Interference Screw, 9 mm x 23 mm BioComposite Interference Screw, 10 mm x 23 mm AR-1586R AR-1510R AR-1778R-30 AR-1510H AR AR AR AR AR AR-1405LP LP AR-8923 AR-1586S AR-1586ST-90 AR-1844 AR-1861 AR-1204R-06S - 105S AR-1204R-11S AR-1204R-12S AR-1250RP AR-1587S AR-1586RB-07 AR-1586RB-08 AR-1586RB-09 AR-1586RB-10 AR-1586RC-07 AR-1586RC-08 AR-1586RC-09 AR-1586RC-10 AR-8920 AR-8922 AR-1370B AR-1380B AR-1390B AR-1400B AR-1360C AR-1370C AR-1380C AR-1390C AR-1400C Suture: #2 FiberWire, 38 inches, 2 strands (1 blue, 1 white/black), qty. 12 AR-7201 FiberStick, #2 FiberWire, 50 (blue) one end stiffened, 12 inches, qty. 5 AR-7209 #2 FiberLoop w/straight Needle, qty. 12 AR-7234 This description of technique is provided as an educational tool and clinical aid to assist properly licensed medical professionals in the usage of specific Arthrex products. As part of this professional usage, the medical professional must use their professional judgment in making any final determinations in product usage and technique. In doing so, the medical professional should rely on their own training and experience and should conduct a thorough review of pertinent medical literature and the product s Directions For Use. U.S. PATENT NOS. D378,780; 5,211,647; 5,320,626; 5,350,383; 5,425,733; 6,461,373; 6,716,234; 7,029,490 and PATENTS PENDING 2011, Arthrex Inc. All rights reserved. LT0198B

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