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A Percutaneous Technique to Reposition the Cortical Button of Adjustable-Loop Devices in Anterior Cruciate Ligament Reconstruction.

ABSTRACT: Adjustable-loop devices are relatively new but quite popular and have been routinely used for around a decade in arthroscopic anterior cruciate ligament reconstruction for hamstring graft fixation on the femur. They allow surgeons to adapt to different tunnel lengths, eliminate the need for multiple loop sizes, decrease the "bungee cord effect," maximize the amount of graft within the femoral socket available for incorporation, and allow retensioning of the graft. Apart from these advantages, certain complications are associated with the use of adjustable-loop devices. When the cortical button is being pulled up through the femoral tunnel, it may be pulled up with greater force, causing it to come out of the vastus lateralis, the iliotibial band, or even the skin. When the graft is pulled back from the tibial side, the cortical button may flip in the substance of the vastus lateralis or outside the iliotibial band. This soft-tissue interposition can cause ischemic necrosis of the interposed tissue, soft-tissue irritation, migration of the cortical button, or early loosening of the graft, leading to anterior cruciate ligament reconstruction failure. We describe a percutaneous solution to this common intraoperative technical complication. The outer sheath of a 4.5-mm arthroscope, 4.5-mm acromionizer, or notchplasty burr can be safely used to put the cortical button back against the lateral cortex of the femur.

SUBMITTER: Sabat D

PROVIDER: S-EPMC6926299 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Self-flip Technique of the TightRope RT Button for Soft-Tissue Anterior Cruciate Ligament Reconstruction.

Project description:The TightRope RT (Arthrex, Naples, FL) is a suspensory device for anterior cruciate ligament reconstruction. However, there is a potential risk of the button being pulled too far off the lateral femoral cortex into the soft tissue because the adjustable loop is long. The purpose of this article is to present an easy and safe technique for self-flip. As to the preparation of the graft, we draw the first line in the loop of the TightRope RT at the same length as the femoral tunnel, and we draw the second line 7 mm longer than the length of the femoral tunnel as a self-flip line. Concerning passing of the graft, the side sutures are pulled from the lateral side. We stop pulling the sutures just at the self-flip line by holding the graft at the tibial end. The side suture is inclined to the medial side with strong pulling of the suture at full extension of the knee. Then the surgeon pulls the tibial end of the graft to feel a secure positioning of the button on the lateral femoral cortex. Although it has limitations, the present technique is easy and certainly helps surgeons achieve appropriate positioning of the button.

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Arthroscopic Technique to Reduce Suture Button Migration During Anterior Cruciate Ligament Reconstruction Procedure.

Project description:Suture button-based femoral cortical suspension constructs of anterior cruciate ligament grafts can facilitate a fast and secure fixation. However, there are several case reports showing button malpositioning resulting from the inability to visualize the "flipped" button. Many current surgical techniques do not allow direct visualization of EndoButtons (Smith & Nephew, Andover, MA) in their final position, making it difficult to ensure that both buttons are fully flipped and that there is no soft-tissue interposition between the button and femur. We describe an arthroscopic technique for making femoral tunnels through the outside-in method that reduces the migration of the EndoButton through a lateral femoral portal. This technique may assist surgeons in understanding how to deal with and potentially avoid EndoButton migration during anterior cruciate ligament reconstruction.

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Graft Retensioning Technique Using an Adjustable-Loop Fixation Device in Arthroscopic Anterior Cruciate Ligament Reconstruction.

Project description:Anterior cruciate ligament (ACL) tears are an unfortunate and devastating injury in the athletic patient. Surgical reconstruction of the ACL with a taut graft construct is necessary to restore knee stability and help expedite the patient's return to an active lifestyle. Arthroscopy-assisted ACL reconstruction can be a technically involved procedure, where strong fixation limits graft motion to allow sufficient healing within the tibial and femoral tunnels at the bone-tendon interfaces. Loss of tension in a graft can cause symptomatic anterior or rotatory instability and potential retear of the ACL graft. We describe in this Technical Note and accompanying video a simple and effective technique to implant and retension a tendon graft during ACL reconstruction using a suspensory fixation device. The technical description uses a simple adjustable-loop device to provide strong cortical fixation, along with the unique ability to retension the graft in ACL reconstruction, not otherwise possible with previously described graft fixation techniques.

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Adjustable Button Devices for All-Arthroscopic Posterior Cruciate Ligament Reconstruction Using the Hamstrings Tendons and the "Forgotten" Transseptal Approach.

Project description:Posterior cruciate ligament (PCL) ruptures account for nearly 20% of all ligamentous knee injuries. These may be either isolated or in the setting of a more complex knee trauma. Isolated tears with moderate posterior laxity (grades I or II) are commonly treated conservatively; nevertheless, symptomatic grade III injuries frequently require surgical intervention. PCL reconstruction remains a challenging surgery for multiple reasons like the neurovascular structures' proximity, the difficult passage of the graft with the "killer turn" angle, or the risk of poor graft fixation. We describe an all-inside operative technique using hamstrings tendon autografts with tibial and femoral adjustable buttons cortical fixation and the visualization of the posterior transseptal portal.

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A new anterior cruciate ligament reconstruction fixation technique (quadrupled semitendinosus anterior cruciate ligament reconstruction with polyetheretherketone cage fixation).

Project description:Fixation of the graft during anterior cruciate ligament reconstruction surgery has been the subject of numerous technical innovations but still remains a challenge. This article describes a novel technique of graft fixation for hamstring tendon reconstruction: the Cage For One system (Sacimex, Aix-en-Provence, France). The technique uses only the semitendinosus tendon, which is looped to create a 4-strand graft. Leaving the gracilis tendon intact probably reduces the loss of knee flexion strength. The graft is indirectly anchored into both tunnels with polyetheretherketone cages by use of polyethylene terephthalate tape strips. Both cages and strips are magnetic resonance imaging compatible and do not create artifacts. The tunnels are drilled by an outside-in method with minimal incisions. This type of fixation creates a 360° bone contact at 1.5 cm in each tunnel and is compatible with double-bundle reconstruction. This easy-to-use novel technique of fixation for anterior cruciate ligament reconstruction produces a strong 4-strand graft while harvesting only the semitendinosus tendon and leaving the gracilis tendon intact to reduce flexion strength loss and preserve rotatory stability of the knee. It creates an immediate solid fixation that is independent of graft integration in the early postoperative period, allowing the patient to start immediate rehabilitation without the use of a brace.

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Hamstring Braid Graft Technique for Anterior Cruciate Ligament Reconstruction.

Project description:Hamstring autograft is one of the most used grafts for anterior cruciate ligament (ACL) reconstruction, although there are several graft preparation techniques. It is extremely difficult to mimic the biomechanical properties of the native ACL; thus, it is important to achieve a proper graft configuration, diameter, and length. To avoid reruptures, an optimal and reproducible hamstring autograft is desired. Hamstring autograft has been traditionally devalued when compared with other options such as bone-patellar tendon-bone autograft. The purpose of this Technical Note is to describe in detail a hamstring braid graft configuration that could potentially overcome the past disadvantages of ACL reconstruction.

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Project description:The awareness of anterior cruciate ligament (ACL) injuries and their treatment is increasing among athletes and within the general population, so patients report early to orthopaedic surgeons. Because we encounter a thick ACL stump during arthroscopic ACL reconstruction, an attempt is made to preserve this stump. Remnant preservation-although promising in terms of graft healing because it enhances cell proliferation, revascularization, and regeneration of the proprioceptive organs in the reconstructed ACL-does not come without complications, such as cyclops lesions, impingement, and extension loss. These problems can be detrimental to an athlete's return to his or her preinjury level after ACL reconstruction. Therefore, we describe a technique in which the ACL is reconstructed using hamstring autograft and suture passes are made through the remnant with an antegrade suture-passing device. After anatomic tunnel drilling, the remnant is tensioned, along with the reconstructed ACL, at the femoral end without the use of an extra implant. Femoral-side fixation is achieved with an adjustable-loop button (Procinch; Stryker) and a bio-composite interference screw (Biosure Regenesorb; Smith & Nephew) on the tibial end. As the sutured remnant is tensioned and knots are made over the button, the remnant envelopes the graft in the orientation of the native ACL, which can be helpful for early and better ligamentization of the graft. The potential advantages of this technique are as follows: orientation of the remnant along the collagen of the ACL graft; no loose ACL stump in the notch, thus preventing cyclops lesions; retention of the proprioceptive organs in the ligament; and no extra implant.

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Quadruple Semitendinosus Graft Construct and Suspensory Button Fixation for Anterior Cruciate Ligament Reconstruction.

Project description:Surgical techniques for anterior cruciate ligament reconstruction are evolving, becoming less invasive, with fewer and smaller incisions, preservation of knee bone stock and tendons at the donor site, and better graft positioning and fixation. We describe an anterior cruciate ligament reconstruction technique that aims to preserve bone stock and spares the gracilis. The semitendinosus graft construct is prepared in a quadruple way and fixed with a cortical button in both tunnels, with increased stiffness and resistance of the graft construct. The tibial tunnel is filled at the end of the operation with a bone dowel, keeping the bone stock intact. This technique is safe, with a short learning curve; preserves the gracilis; saves bone; and increases the stiffness and resistance of the tibial fixation.

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Project description:During the past few decades, surgical techniques for anterior cruciate ligament (ACL) reconstruction have been developing significantly. To date, studies have shown that after ACL reconstruction, rotational stability has a greater impact on the patient's satisfaction, functional scores, and return to sports than translational stability. Although challenged by many authors in the literature, biomechanical studies on the anterolateral ligament (ALL) of the knee and clinical studies regarding ALL reconstruction have been revealing promising results. Thus, the potentially significant role of the ALL in biomechanical load sharing and improving rotational control of the knee has led to the development of various reconstruction techniques whose goal is to achieve simplicity and yield the best results possible. Guided by this idea, we have developed a modified ACL-ALL reconstruction surgical technique. In this article, our simple, bone-saving, anatomic technique to reconstruct both the ACL and ALL using hamstring tendon autograft is described.

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