Two Techniques for Fixing an Achilles Tendon Allograft with the WasherLoc Device

Transcription

1 Two Techniques for Fixing an Achilles Tendon Allograft with the WasherLoc Device S U R G I C A L T E C H N I Q U E SINGLE TAIL TECHNIQUE DEVELOPED IN CONJUNCTION WITH THOMAS D. MEADE, M.D. DOUBLE TAIL TECHNIQUE DEVELOPED IN CONJUNCTION WITH KEVIN BONNER, M.D.

2 surgical technique Introduction Orthopedic surgeons use a variety of allograft tissues to reconstruct a torn anterior cruciate ligament (ACL). One tissue being used more frequently is the Achilles tendon allograft. 1-4 The Achilles tendon allograft has three advantages over a patellar tendon bone allograft. These advantages include increased availability, a larger cross-sectional area providing a stronger and stiffer graft and the avoidance of tunnel-graft length mismatch because the tendon always extends beyond the end of the tibial tunnel. The use of the WasherLoc washer and screw has several advantages over other tibial fixation devices used to fix the tendon end of an Achilles tendon allograft. The WasherLoc washer construct shortens graft length by fixing the tendon inside the distal end of the tibial tunnel. 5 Placing the WasherLoc inside the distal end of the of the tunnel does not interfere with the biologic formation of the interface between the tendon and tunnel wall, which is a complication of devices that are placed along the length of the tunnel such as the interference screw. 6 The WasherLoc washer and screw are inserted into cortical bone, which provides better strength, stiffness and resistance to slippage than cancellous fixation devices. 5 Cancellous fixation devices are especially ineffective in females and osteoporotic patients. 7 The WasherLoc washer is countersunk inside the tibial tunnel, which nearly eliminates the need for hardware removal. 5, 8 The WasherLoc washer is a significant advance over staples, washers, screws and buttons placed on the tibial cortex because they require removal in 12-26% of patients Finally, the WasherLoc washer is available in three diameters, 14, 16 and 18mm allowing matching of the diameter of the washer to the graft.

3 Prepare the Achilles Allograft The surgeon or an assistant can prepare the Achilles tendon allograft. The surgeon should prepare the allograft before beginning the surgical procedure on the knee to minimize tourniquet time and anesthesia. The assistant can prepare the graft simultaneous with the surgical procedure shortening the time in the operating theatre. Use a micro oscillating saw, burr and small rongeur to shape the bone end of the Achilles allograft into a bullet that is 10mm in diameter and 24mm in length. Confirm the bone plug is correctly sized by passing it through a 10mm sizing sleeve. Drill a 2.4mm diameter hole centered in the proximal half of the bone plug. Drill a 1.6mm diameter hole centered Figure 1 in the distal half of the bone plug. Pass the needle attached to the #5 Ethibond suture through the proximal hole. Pass the needle attached to the #1 Ethibond suture through the distal hole (Figure 1). Use methylene blue or a pen to mark the tendon where it joins the bone plug. Trim the tendon end of the Achilles allograft to a width of 10mm. Maintain the full length of the tendon so that the tendon extends beyond the tibial tunnel and can be grasped for tensioning. Preparation of Single Tail: Use a #1 non-absorbable suture and sew the distal 4cm of the tendon using a criss-crossing or Krakow stitch (Figure 2). Preparation of Double Tail: Use a knife and split the Achilles tendon into two tails approximately 3 to 4 cm from its insertion on the bone plug. Tubularlize each tail of the distal 4 cm of tendon using a criss-crossing or Krakow stitch of #2 non-absorbable suture (Figure 3). Tension the allograft on a tension board. Apply 20 lbs. tension for a minimum of five minutes or until the graft is implanted (Figure 4). Wrap a gauze soaked in antibiotic saline over the graft. Drill the Tibial Guide Wire The Howell Tibial Guide with Coronal Alignment Pin is used to percutaneously place a guide wire posterior and parallel to the slope of the intercondylar roof with the knee in full extension at an angle of 65 to the medial tibial plateau in the coronal plane. 11 (Figures 5a & b). Use a probe and check the clearance between the lateral edge of the posterior cruciate ligament and the guidewire. If the clearance is less than 3mm, then use a 3mm hole changer to move the guide wire more lateral. 1 Figure 2 Figure 4 Figure 5a Figure 3 Figure 5b achilles tendon

4 surgical technique Expose the Tibia Make a longitudinal skin incision incorporating the guide wire (Figure 6). Extend the incision 2.5cm proximal and 1.5 cm distal to the guide wire. Incise the fascia, medial collateral ligament and periosteum in line with the skin incision using electrocautery. Use a small Cobb elevator to elevate the tissue flaps medial and lateral to Figure 6 expose a 2.5 cm elliptical section of tibia. Retract the tissue flaps using a small Gelpi retractor. Drill the Tibial Tunnel and Counterbore Drill the tibial tunnel using a 10mm cannulated reamer. Insert the counter bore guide into the tibial tunnel until the vertical sleeve is compressed against the distal end of the anterior edge of the tibial tunnel. Rotate the guide until the crosspin parallels the anteromedial cortex of the tibia. Point the vertical sleeve towards the fibula (Figure 7). Impact the awl through the sleeve toward the fibula until it is fully seated or touches the medial cortex of the tibia. Aiming the awl toward the fibula avoids damage to the posterior neurovascular structures, which lie superficial to the popliteus muscle in the midline (Figures 8a & b). Figure 8a Figure 9a Figure 7 Figure 8b Figure 9b Remove the guide and place the awl in the pilot hole to maintain orientation. The long axis of the awl should be perpendicular to the posterior wall of the tibial tunnel. Memorize the orientation of the awl, remove it, and insert the tip of the counter bore into the pilot hole. Maintain the cutting surface of the counter bore parallel to the posterior wall of the tibial tunnel (Figures 9a & b). Ream until the counter bore is flush with the posterior wall of the tibial tunnel. 2

5 3 Perform a Roof and Wallplasty A roof and wallplasty is often necessary to prevent conflict between the graft with the intercondylar roof during knee extension exercises and aggressive rehabilitation because the Achilles Allograft is wider than the keyhole shape of the notch and the tibia translates anteriorly with active knee extension exercises (Figure 10). Use the angled osteotome and curved gouge to remove bone from the lateral wall and intercondylar roof. Contour and smooth the notch with a motorized burr. Confirm roof impingement has been eliminated by inserting an impingement rod through the tibial tunnel and into the intercondylar notch with the knee in full extension. Prepare the Femoral Tunnel Use the angled curette to remove remnants of the ACL origin from the over-the-top position, which allows the over-the-top femoral aimer to rest on bone preventing blow-out of the posterior wall (Figure 11). Select a femoral aimer that is the same size as the graft, which is designed to retain 1mm of bone on the posterior wall of the femoral tunnel. Insert the aimer through the tibial tunnel and hook it in the over-the-top position. Flex the knee until the guide locks in place. Rotate the tip of the aimer away from the posterior cruciate ligament (Figure 12). Drill a 3/32 inch spade tip passing pin through the femoral aimer until it exits through the anterolateral skin of the distal thigh (Figure 13). Figure 10 Figure 11 Figure 13 Figure 14 Drill a 10mm in diameter 35mm in length closed end femoral tunnel using an acorn-tip cannulated femoral reamer. Drilling the tunnel slightly longer than the 24mm bone plug provides leeway when pulling the bone plug in case of retained bone debris, a miscalculation, or obliquity of the intraarticular opening of the bone tunnel. Fold a #2 steel wire into a loop. Pass 2 cm of the free end of the loop through the eyelet of the shoulder pin and fold the free end over the eyelet. Pull the shoulder pin through the distal thigh until 2 cm of the loop protrudes from the tibial tunnel (Figure 14). Figure 12 Proceed to either the single tail (pg. 4 5) or double tail (pg. 6 7) technique. achilles tendon

6 S I N G L E T A I L surgical technique Insert the Achilles Tendon Allograft Remove the Achilles tendon allograft from the tension board. Pass the #5 and #1 Ethibond sutures threaded through the bone plug through the loop in the steel wire (Figure 15). Pull the pin and wire loop out through the anterolateral thigh. Clamp the sutures with a Kocher clamp. Pull the bone plug into the femoral tunnel until the methylene blue mark is flush with the opening of the femoral tunnel (Figures 16 & 17). Figure 16 Figure 17 Figure 15 Fix the Achilles Allograft to the Femur with an Interference Screw Insert a solid, non-cannulated screwdriver through the medial portal. Impact the screwdriver with a mallet to make a starting notch in the femoral tunnel on the anterior surface of the bone plug for a cannulated interference screw. Remove the screwdriver and advance the interference screw guide wire 2 cm into the notch between the bone plug and tunnel wall. Direct an assistant to simultaneously pull on the Achilles allograft outside the femur and tibia to maintain graft position during insertion of the interference screw. Screw a 7mm x 20mm interference fit screw over the guide wire until it is flush with the bone plug (Figures 18 & 19). Figure 18 Figure 19 4

7 5 Fix the Achilles Allograft to the Tibia with the WasherLoc System Make a 3 cm longitudinal incision in the middle of the Achilles tendon a the level of the tibial tunnel opening (Figure 20). Thread the awl into the drill guide and the drill guide into the 18mm (in diameter) WasherLoc (Figure 21). With the knee in full extension and approximately 20 lbs. of tension applied to the free tendon end, the WasherLoc device is driven in securing the tendon flush against the posterior wall (Figure 22) of the tibial tunnel (Figure 23a & b). Figure 21 Figure 20 Figure 22 Figure 23a Precautions: Keeping tension on the graft during drilling of the posterior cortex and screw insertion helps prevent any graft damage. Overdrilling with the counterbore reamer below the level of the posterior tibial tunnel can result in both tensioning and attachment difficulties. Figure 23b Figure 24b Figure 26 Figure 28 Remove the awl and use a 3.2mm drill bit to carefully drill through the lateral tibial cortex (Figures 24a & b). Measure the length of the screw with a depth gauge (Figure 25). Select a cancellous WasherLoc screw the same length that was measured. Coat the first two threads of the WasherLoc screw with bone wax (Figure 26). Insert the WasherLoc screw until it firmly purchases the lateral cortex of the tibia (Figure 27). Closure of the Tibial Incision A small pyramid-shaped piece of cancellous calcaneal bone is wedged into the tibial tunnel opening to prevent excess bleeding and synovial fistula from forming (Figure 28). Bone wax is also used on any exposed cancellous bone. Excess tendon is amputated at the level of the WasherLoc and the periosteum is closed with interrupted #1 absorbable sutures. The skin and portals are closed with nylon. Figure 24a Figure 27 Figure 25 achilles tendon

8 D O U B L E T A I L surgical technique Insert the Achilles Tendon Allograft Remove the Achilles tendon allograft from the tension board. Pass the #5 and #1 Ethibond sutures threaded through the bone plug through the loop in the steel wire (Figure 15). Pull the pin and wire loop out through the anterolateral thigh. Clamp the sutures with a Kocher clamp. Pull the bone plug into the femoral tunnel until the methylene blue mark is flush with the opening of the femoral tunnel (Figures 16 & 17). Figure 16 Figure 17 Figure 15 Fix the Achilles Allograft to the Femur with an Interference Screw Insert a solid, non-cannulated screwdriver through the medial portal. Impact the screwdriver with a mallet to make a starting notch in the femoral tunnel on the anterior surface of the bone plug for a cannulated interference screw. Remove the screwdriver and advance the interference screw guide wire 2 cm into the notch between the bone plug and tunnel wall. Direct an assistant to simultaneously pull on the Achilles allograft outside the femur and tibia to maintain graft position during insertion of the interference screw. Screw a 7mm x 20mm interference fit screw over the guide wire until it is flush with the bone plug (Figures 18 & 19). Figure 18 Figure 19 6

9 7 Fix the Achilles Allograft to the Tibia with a WasherLoc Washer Thread the awl into the drill guide and the drill guide into the 18mm WasherLoc screw (Figure 20). Put the knee in full extension. Place the tip of the awl through the two tails of the graft. Use a right-angle clamp to maneuver the sides of the graft within the four long peripheral spikes of the WasherLoc washer (Figure 21). Manually apply tension to the graft. Advance the tip of the awl into the hole in the tibial tunnel and orient the awl toward the fibula. Impact the WasherLoc washer into the tibia (Figures 22a & b). Remove the awl and use a 3.2mm drill bit to carefully drill through the lateral tibial cortex (Figures 23a & b). Measure the length of the screw with a depth gauge (Figure 24). Select a cancellous WasherLoc screw which is the same length as measured. Coat the first two threads of the WasherLoc screw with bone wax (Figure 25). Insert the WasherLoc screw until it firmly purchases the lateral cortex Figure 22a of the tibia (Figure 26). Figure 20 Figure 21 Figure 22b Figure 23b Figure 25 Figure 27 Closure of the Tibial Incision Wedge a cancellous piece of the calcaneous between the anterior surface of the tendon and the wall of the tibial tunnel to enhance biologic fixation and reduce bleeding (Figure 27). Press bone wax into exposed cancellous bone. Amputate the tendon 1 cm distal to the WasherLoc screw. Close the tissue flaps with interrupted #1 absorbable sutures. Figure 24 Figure 23a Figure 26 achilles tendon

10 surgical technique References 1. Linn RM, Fischer DA, Smith JP, Burstein DB, Quick DC. Achilles tendon allograft reconstruction of the anterior cruciate ligament-deficient knee. American Journal of Sports Medicine. 1993; 21(6): Vangsness CT, Jr., Triffon MJ, Joyce MJ, Moore TM. Soft tissue for allograft reconstruction of the human knee: a survey of the American Association of Tissue Banks. American Journal of Sports Medicine. 1996; 24(2): Noyes FR, Barber-Westin SD, Butler DL, Wilkins RM. The role of allografts in repair and reconstruction of knee joint ligaments and menisci. Instr Course Lect. 1998; 47: McGuire DA, Wolchok JC, Hendricks SD. The use of allografts in ligamentous reconstructions of the knee. Alaska Med. 2001; 43(2): Magen HE, Howell SM, Hull ML. Structural properties of six tibial fixation methods for anterior cruciate ligament soft tissue grafts. American Journal of Sports Medicine. 1999; 27: Singhatat W, Lawhorn K, Howell SM, Hull ML. How four weeks of implantation effect the strength an stiffness of a tendon graft in a bone tunnel: A study of two fixation devices in an extraarticular model in bovine. American Journal of Sports Medicine. 2001: In press. 7. Corry IS, Webb JM, Clingeleffer AJ, Pinczewski LA. Arthroscopic reconstruction of the anterior cruciate ligament. A comparison of patellar tendon autograft and four-strand hamstring tendon autograft. American Journal of Sports Medicine. 1999;27(4): Howell SM, Deutsch ML. Comparison of endoscopic and two-incision technique for reconstructing a torn anterior cruciate ligament using hamstring tendons. Journal of Arthroscopy. 1999; 15(6): Clark R, Olsen RE, Larson BJ, Goble EM, Farrer RP. Cross-pin femoral fixation: A new technique for hamstring anterior cruciate ligament reconstruction of the knee. Arthroscopy. 1998; 14(3): Siegel MG, Barber-Westin SD. Arthroscopic-assisted outpatient anterior cruciate ligament reconstruction using the semitendinosus and gracilis tendons. Arthroscopy. 1998; 14(3): Howell SM, Gittins ME, Gottlieb JE, Traina SM, Zoellner TM. The relationship between the angle of the tibial tunnel in the coronal plane and loss of flexion and anterior laxity after anterior cruciate ligament reconstruction. American Journal of Sports Medicine. 2001; 29(5): Howell SM, Taylor MA. Brace-free, rehabilitation, with early return to activities, in knees reconstructed with a double-looped, semitendinosus and gracilis graft. Journal of Bone and Joint Surgery. 1996: Howell SM, Taylor MA. Failure of reconstruction of the anterior cruciate ligament due to impingement by the intercondylar roof. Journal of Bone and Joint Surgery Am. 1993; 75(7): Howell SM, Berns GS, Farley TE. Unimpinged and impinged anterior cruciate ligament grafts: MR signal intensity measurements. Radiology. 1991; 179(3): Goss B, Howell S, Hull M. Quadriceps load aggravates and roofplasty mitigates active impingement of anterior cruciate ligament grafts against the intercondylar roof. Journal of Orthopaedic Research. 1998; 16: Bone Mulch, LactoScrew, Gentle Threads, Howell and WasherLoc are trademarks of Arthrotek, Inc. LactoSorb is a trademark of Biomet, Inc. This brochure is presented to demonstrate the surgical techniques utilized by Thomas D. Meade, M.D. and Kevin Bonner, M.D. Arthrotek, as the manufacturer of this device, does not practice medicine and does not recommend this or any other surgical technique for use on a specific patient. The surgeon who performs any procedure is responsible for determining and utilizing the appropriate techniques for such procedure for each individual patient. Arthrotek is not responsible for selection of the appropriate surgical technique to be utilized for an individual patient. 8

11 Ordering Information Gentle Threads Resorbable Interference Screws 9 Fully Threaded LactoSorb Copolymer Interference Screws Part No mm x 20mm mm x 25mm mm x 30mm mm x 20mm mm x 25mm mm x 30mm mm x 20mm mm x 25mm mm x 30mm mm x 20mm Revision LactoSorb Copolymer Interference Screws Part No mm x 25mm mm x 25mm Titanium Interference Screws Part No. Fully Threaded Titanium Interference Screws mm x 20mm mm x 25mm mm x 30mm mm x 20mm mm x 25mm mm x 30mm mm x 20mm mm x 25mm mm x 30mm Round Headed LactoSorb Copolymer Interference Screws Part No mm x 20mm mm x 25mm mm x 20mm mm x 25mm mm x 20mm mm x 25mm mm x 25mm Instrumentation LactoScrew Copolymer Interference Screw Driver Tunnel Dilator Tunnel Notcher Part No. Round Headed Titanium Interference Screws mm x 15mm mm x 20mm mm x 25mm mm x 15mm mm x 20mm mm x 25mm mm x 20mm mm x 25mm mm x 30mm mm x 20mm mm x 25mm mm x 30mm mm x 15mm mm x 20mm mm x 25mm mm x 30mm mm x 20mm mm x 25mm mm x 30mm LactoSorb Copolymer Interference Screw Instrument Tray mm Nitinol Guide Wire Gentle Threads Disposable Kit Easy Out Screw Driver Thin Shafted Driver Revision Gentle Threads Screwdriver Compatible with and Revision Gentle Threads Dilator Instrumentation Cannulated Screwdriver mm Hex Non Cannulated Hex Driver mm Hex Nitinol Guide Wire mm 14" Long mm 9" Long Graft Passing Pin Graft Prep Table Graft Sizing Block ARTHROTEK 7mm 8mm 5mm 10mm 15mm 20mm 25mm 30mm 35mm 9mm GRAFT SIZER mm 11mm 12mm achilles tendon

12 WasherLoc System WasherLoc Screws Cortical Cancellous mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm mm Part No. WasherLoc Washer mm mm mm Hole Changers Body mm Tip mm Tip Cannulated Drill Bit mm WasherLoc Tunnel Guide WasherLoc Awl WasherLoc Counter Bore Impingement Rod mm Tunnel Rasp Angle Osteotome Curved Roofplasty Gouge Bone Mulch /WasherLoc Disposable Kit Curette Over-the-Top Curette Femoral Aimer Tip mm Femoral Aimer Handle " Guide Pin/Graft Passing Pin Cannulated End Cutting Reamer mm Screwdrivers mm Hex mm Hex WasherLoc Inserter/Drill Guide WasherLoc 3.2mm Drill Bit WasherLoc Depth Gauge Cruciate Screwdriver Instrumentation Sizing Sleeve mm Howell Tibial Guide with Coronal Alignment Sharp Drill Guide Bullet Calibrated (for Howell Tibial Guide) Coronal Alignment Pin Drill Point K-wire mm Frozen Aseptic Frozen Sterilized Allografts Patella Tendon Struts (BTB, Hemi) Bone Struts 1.5 cm (w) x 3 cm (l) x 1 cm (h) Patella Tendon Struts (BTB, Whole Right) Patella Tendon Struts (BTB, Whole Left) Anterior Tibialis Tendon 0.5 cm (w) x 20 cm (l) Posterior Tibialis Tendon 0.5 cm (w) x 20 cm (l) Semitendinosus and Gracilis Tendon 20 cm (l) Achilles Tendon with Bone Strut Tendon 1.5 cm (w) x 20 cm (l) Achilles Tendon without Bone Strut Tendon 1.5 cm (w) x cm (l) Quadricep Tendon with Patella Bone Strut 1.5 cm (w) x 3 cm (l) x 1 cm (h) Tendon 1.5 cm (w) x 16 cm (l) Bone Strut 12 15mm (w) x 3 cm (l) x 1 cm (h) P.O. Box 587, Warsaw, IN Arthrotek, Inc. All Rights Reserved web site: Domestic arthrotek@arthrotek.com International arthrotekeurope@arthrotek.com Form No. Y-BMT-751/051502/K