GraftLink All-Epiphyseal, All-Inside ACL Reconstruction with ACL TightRope ABS Surgical Technique

GraftLink All-Epiphyseal, All-Inside ACL Reconstruction with ACL TightRope ABS Surgical Technique GraftLink All-Epiphyseal ACL

The incidence of ACL injury has increased substantially over the last 2-3 decades in all age groups due to demographic changes. The pediatric and young adolescent population has also been seen to have a rapidly increasing incidence due to their escalating participation in sports, the level of competition within these sports and the influence of Title IX, which has doubled the denominator by including female persons in athletics. This has resulted in more pediatric and young adolescent injuries. Nonoperative treatment of a complete ACL tear in active, athletic, adolescent patients has been demonstrated to have a poor natural history. The majority of these individuals will go on to develop progressive damage to the menisci and articular cartilage. This damage has been shown to lead to early arthritis in young adults. Historically, the skeletally immature athlete with a complete ACL tear was either treated with benign neglect or some combination of extraarticular and intraarticular reconstruction (to avoid injury to the physis) often necessitating arthrotomy with the associated morbidity and local soft tissue trauma. These were not operations that would be performed in the adult population with an ACL tear. More modern surgical techniques have been developed, but they do not restore the native ACL footprints (over-the-top-ot) and go through the physis with the potential for growth disturbance (partial or complete transphyseal). The all-epiphyseal ACL reconstruction has recently been considered as an alternative because of improvements in instrumentation. We have further refined the procedure originally described by Anderson (transepiphyseal ACL reconstruction) to allow for a minimally invasive all-inside, allepiphyseal reconstruction. This utilizes the RetroConstruction technique with specifically designed small angle guides. The RetroConstruction technique creates blind sockets with a cortical bone bridge rather than tunnels with openings at both ends. The all-inside technique has been performed in adults and based upon our experience with this procedure and instrumentation in the adult population, we developed this technique for use in the pediatric and young adolescent populations. We are performing ACL reconstructions in the skeletally immature athlete utilizing these principles. Essentially performing a reconstruction in the skeletally immature - now with the ability to do so without compromising the physis. - Frank A. Cordasco, M.D. and Daniel W. Green, M.D. All-Epiphyseal

GraftLink Minimally Invasive All-Epiphyseal, All-Inside ACL Reconstruction Staying true to the RetroConstruction product line, these unique small angle marking hooks allow surgeons to perform the most anatomic, minimally invasive and reproducible all-inside, all-epiphyseal ACL reconstruction using the GraftLink technique in skeletally immature patients. Anatomic Independent tibial and femoral socket preparation with FlipCutter II or Short FlipCutter II facilitates unconstrained placement of the ACL graft within the epiphyses, while avoiding the physis. Minimally Invasive Single hamstring harvest decreases morbidity and loss of strength.* Socket preparation with FlipCutter II or Short FlipCutter II limits soft tissue dissection and preserves bone and periosteum. Reproducible The GraftLink workstation simplifies graft preparation. The tapered graft and adjustable femoral and tibial ACL TightRope buttons facilitate graft passing, fine tuning of graft depth, and graft tensioning from the femoral and tibial sides. Small Angle Footprint Femoral ACL Guide - AR-1510FRS Small Angle Pin Tip Tibial Marking Hook ACL Guide - AR-1510GTS Supporting Literature 1. Anderson AF, Transepiphyseal replacement of the anterior cruciate ligament in skeletally immature patients. A preliminary report. J Bone Joint Surg Am 2003;85: 1255-1263. 2. Anderson AF, Transepiphyseal replacement of the anterior cruciate ligament using quadruple hamstring grafts in skeletally immature patients, J Bone Joint Surg Am 2004; 86:201-209 (suppl 1). 3. Fabricant PD; McCarthy MM; Cordasco FA; Green DW, All-Inside, All-Epiphyseal Autograft Reconstruction of the Anterior Cruciate Ligament in the Skeletally Immature Athlete: A Surgical Technique. J Bone Joint Surg Am Surgical Techniques, 2013, May 08;3(2):e9 1-13. 4. Fabricant PD; Jones K; Delos D; Cordasco FA; Marx RG; Pearle AD; Warren RF; Green DW, Reconstruction of the Anterior Cruciate Ligament in the Skeletally Immature Athlete: A Review of Current Concepts, J Bone Joint Surg Am. 2013, March 06;95(5):e28 1-13. 5. Kercher J; Xerogeanes J; Tannenbaum A; Al-Hakim R; Black JC; Zhao J, Anterior cruciate ligament reconstruction in the skeletally immature: An anatomical study utilizing 3-dimensional magnetic resonance imaging reconstructions, J Pediatric Orthop 2009;29:124-129. 6. Lawrence JT; Bowers AL; Belding J; Cody SR; Ganley TJ, All-epiphyseal anterior cruciate ligament reconstruction in skeletally immature patients, Clin Orthop Relat Res 2010;468: 1971-1977. 7. McCarthy MM; Tucker S; Green DW; Imhauser C; Cordasco FA, Contact Stress and Kinematic Analysis of All-Epiphyseal and Over-the-Top Pediatric Reconstruction Techniques for the Anterior Cruciate Ligament, AJSM 2013. 8. McCarthy MM; Graziano J; Green DW; Cordasco FA, All-Epiphyseal, All-Inside Anterior Cruciate Ligament Reconstruction Technique for Skeletally Immature Patients, Arthroscopy Tech 2012; 1(2):231-9. 9. Milewski MD; Beck NA; Lawrence JT; Ganley TJ, Anterior cruciate ligament reconstruction in the young athlete: A treatment algorithm for the skeletally immature, Clin Sports Med 2011;30:801-810. 10. Xerogeanes JW; Hammond KE; Todd DC, Anatomic Landmarks Utilized for Physeal-sparing, Anatomic Anterior Cruciate Ligament Reconstruction: An MRI-based study, J Bone Joint Surg Am 2012;94: 268-276. *data on file

Graft Preparation 1 The GraftLink Graft Prep Attachments are placed on the base and the ACL TightRope implants are loaded into the attachments. The distance between TightRope loop ends is measured. This distance should equal 10 mm less than the desired final graft length. In this example, a TightRope is used for femoral fixation and a TightRope ABS is used for tibial fixation. Alternatively, a TightRope RT may be used for tibial fixation. a 2 b The overall graft length is measured. (Note: a length of 25 cm will yield a four-stranded GraftLink of at least 5 cm.) Load the graft through the implants by folding it symmetrically over the loops. Stitch both graft ends together with a single #2 FiberLoop after passing the graft through ACL TightRopes (a). Alternatively, stitch approximately 2 cm of each graft end with one #2 FiberLoop and one #2 TigerLoop (b). 3 Pass one tail of each whipstitch over the graft loop and the other under the graft loop. This will ensure that the tails of the graft are tucked inside the loop during tensioning, which will facilitate tapering of ends and uniform thickness of the graft.

4 Once the graft is folded appropriately and the desired length is obtained, wrap the whipstitch sutures around the post to hold the construct in place. 5 The first stitch may now be placed. Using a buried knot technique, start from the inside of the graft and place the needle through the first two graft limbs. 6 Wrap the suture around the graft then place the needle through the second set of graft limbs from outside/in. 7 Tension the suture and tie a knot to secure the stitch.

10 mm 20 mm 20 mm 10 mm 8 This may be repeated on either end of the graft for a total of two stitches on each end. 9 The GraftLink Graft Prep Attachments may now be used for tensioning by simply pulling on one side until the desired tension is obtained, as read on the tensiometer. The FiberLoop whipstitch sutures may be cut off or used as supplemental fixation. Graft Sizing Measure the graft length and diameter. Pass both the femoral and tibial ends of the graft into the sizing block to measure diameter for socket drilling. 15-20 mm 20-25 mm 20 mm Socket Creation The length from the end of the femoral socket to the end of the tibial socket should be at least 10 mm longer than the graft to ensure that the graft can be tensioned fully. Example: 50-55 mm graft length Assuming a maximum intraarticular length of 20-25 mm, there will be approximately 15-20 mm of graft in the femoral and tibial socket. Drill the femur 20 mm deep and the tibia approximately 20 mm deep to allow an extra 10 mm for tensioning.

All-Epiphyseal Femoral Socket Preparation with FlipCutter a 1 Using the side-specific small angle femoral marking hook and stepped drill sleeve, the intraarticular and extraarticular landmarks are identified and confirmed. 10 Note: The intraosseous length on the drill sleeve when pushed down to bone (a). Short FlipCutter II 2 3 The appropriate size FlipCutter II or Short FlipCutter II is drilled through the stepped Drill Sleeve into the joint. Adequate distance and positioning distal to the physis is verified by fluoroscopy. Once the position is confirmed, the FlipCutter II or Short FlipCutter II may be used to create the femoral socket. 8 After flipcutting, pass a FiberStick suture through the stepped Drill Sleeve and dock for later graft passing.

Tibial Socket Preparation 1 2 Using the small angle tibial marking hook and stepped Drill Sleeve, the intraarticular and extraarticular landmarks are identified and confirmed. The FlipCutter II or Short FlipCutter II is drilled through the stepped Drill Sleeve into the joint. Adequate distance and positioning proximal to the physis is verified by fluoroscopy. Flip the blade and lock into cutting position. Drill on forward, with distal traction, to cut the socket. Use the rubber ring and 5 mm markings on the FlipCutter to measure socket depth (inset). Graft Passing 1 2 Straighten the FlipCutter blade and remove from the joint. Pass a TigerStick into the joint and retrieve both the tibial TigerStick and the femoral FiberStick out the medial portal together with an open Suture Retriever. Retrieving both sutures at the same time will help avoid tissue interposition that can complicate graft passing. Note: A PassPort Button Cannula may also be used in the medial portal to prevent tangling. Pass the blue button suture and the white shortening strands through the femur. Remove slack from sutures and ensure equal tension. Clamp or hold both blue and white sutures together and pull them together to advance the button out of the femur. Use markings on the loop and arthroscopic visualization of the button to confirm exit from the femoral cortex. Pull back on the graft to confirm the button is seated.

3 4 While holding slight tension on the graft, pull the shortening strands proximally one at a time, to advance the graft. Pull on each strand in 2 cm increments. Note: The graft can be fully seated into the femur or left partially inserted until tibial passing is complete. The latter option allows fine tuning of graft depth in each socket. Cinch a suture around the end of the TightRope ABS loop to use for passing (inset). Load the cinch suture and the whipstitch tails from the graft into the tibial passing suture. Pull distally on the tibial passing suture to deliver both the TightRope ABS loop and the whipstitch sutures out of the tibia. 5 6 Advance the graft into the tibia by pulling on the inside of the ABS loop and whipstitch sutures. Load the TightRope ABS Button onto the loop. Pull on the white shortening strands to advance the button to bone and tension graft. Note: Ensure the button has a clear path to bone, as to not entrap soft tissue under the button.

7 Load the whipstitch sutures into the button and tie a knot for backup fixation.

Ordering Information Implants ACL TightRope RT AR-1588RT TightRope ABS AR-1588TN TightRope ABS Button AR-1588TB 14 mm TightRope ABS Button AR-1588TB-1 Button Extender AR-1589RT ACL TightRope Convenience Pack AR-1588RTS Autograft GraftLink Convenience Pack AR-1588AU-CP Allograft GraftLink Convenience Pack AR-1588AL-CP Instruments RetroConstruction Drill Guide Set AR-1510S Pin Tip Tibial Marking Hook ACL Guide, small angle AR-1510GTS Footprint Femoral ACL Guide, small angle, right AR-1510FRS Footprint Femoral ACL Guide, small angle, left AR-1510FLS FlipCutter IIs, 6 mm 13 mm AR-1204AF-60 130 Short FlipCutter IIs, 5 mm 12 mm AR-1204AS-50 120 Drill Sleeve for RetroConstruction Drill Guide AR-1510D Accessories Suture Retriever Graft Sizing Block Graft Prep Station Base GraftLink Prep Attachment GraftLink Prep Attachment with Tensioner Suture Cutter for ACL TightRope TightRope Drill Pin, open TightRope Drill Pin, closed Suture AR-12540 AR-1886 AR-2950 AR-2951-1 AR-2951-2 AR-4520 AR-1595T AR-1595TC 0 FiberWire, 38" (blue) w/tapered Needle, 22.2 mm 1/2 circle AR-7250 FiberStick, #2 FiberWire, 50" (blue) one end stiffened AR-7209 TigerStick, #2 TigerWire, 50" (white/black) one end stiffened AR-7209T #2 FiberLoop w/straight Needle, 20 (blue), 76 mm needle w/7 mm loop AR-7234 #2 TigerLoop w/straight Needle, 20 w/tigerwire (white/green), 76 mm needle w/7 mm loop AR-7234T

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. View U.S. Patent information at http://www.arthrex.com/virtual-patent-marking 2015, Arthrex Inc. All rights reserved. LT1-0161-EN_B