All-Inside Anterior Cruciate Ligament Reconstruction with Suture Tape Augmentation: Button Tie-Over Technique (BTOT)

ABSTRACT: The anterior cruciate ligament (ACL) is the most common ligamentous knee injury in pivoting sports. There are multiple techniques described for ACL reconstruction; however, still there is an ongoing debate regarding the optimal technique with minimal residual laxity and least risk of rerupture. All-inside ACL reconstruction with suture tape augmentation (InternalBrace) is a newly developed method of ACL reconstruction to help address these issues. Suture tape protects the graft during ligamentization process. The aim of this article is to describe a modified all-inside ACL reconstruction technique with suture tape augmentation in which the internal brace is tied distally over the distal TightRope button without an extra method of fixation. Technique Video Video 1 The GraftLink is prepared in the standard fashion for all-inside ACL reconstruction. In this technique, only the semitendinosus is harvested. The GraftLink is prepared according to Lubowitz et al..6,10 using FiberWire No. 2 suture. The graft length should be not more than 70 mm. A FiberTape is used to augment the graft. The Tape is shuttled through each hole of the button of the femoral TightRope. Shuttling of the FiberTape through the button can be assisted by a nitinol suture passer. The strands of the FiberTape suture are then crossed and wrapped inside the GraftLink bundles. The 2 free ends of the FiberTape are not loaded over tibial Tightrope at this stage. The ACL femoral socket is drilled from accessory anteromedial portal using Spade tip drill. A low-profile reamer of the same graft size is then used to drill femoral socket to about 30 mm. A shuttle suture is then advanced through cannulated guide pin sleeve. With the arthroscope in the anterolateral portal, the FlipCutter is used in a retrograde manner to create a 30-mm tibial socket. The FlipCutter is pushed back into the knee, flipped back into guide pin mode, and removed. After the FlipCutter is removed, the sleeve is left in place, facilitating simple and reproducible passage of graft-passing sutures for later graft passage, because the sleeve also serves as a cannula. Femoral and tibial graft–passing sutures are retrieved from the anteromedial arthroscopic portal at the same time, to avoid suture tangling or soft-tissue interposition. Once the sutures are not tangled, the femoral TightRope sutures are shuttled through the anteromedial portal. Once the button flips, the graft is then pulled into femoral socket. Next, a back-and-forth tension is applied on each free end of the femoral pull suture, tensioning the graft up into the femoral socket. Usually only 1 to 1.5 cm of the graft is pulled inside femoral socket at this stage. Tibial Tightrope and internal brace sutures are then retrieved through tibial socket to the outside. Once the tibial Tightrope and the internal brace sutures are outside tibial cortex, the traction suture of the TightRope is removed and the FiberTape strands are then shuttled through tibial Tightrope holes alongside with the TightRope suspensory sutures. Now, the tibial TightRope is loaded with 2 white suspensory sutures for graft tensioning and 2 blue sutures for internal brace tensioning. The graft is then pulled through the tibial socket after tensioning the white strands of the tibial Tightrope in knee flexion. The knee is moved through its range of motion, and additional tension may be applied by pulling the femoral or tibial pull sutures by hand. This is followed by InternalBrace tying over tibial TightRope button, in full or even hyperextension and neutral rotation to prevent any over constraining of the knee and to avoid “capturing” the joint in flexion deformity. (ACL, anterior cruciate ligament.)

SUBMITTER: Waly A 

PROVIDER: S-EPMC8626770 | biostudies-literature |

REPOSITORIES: biostudies-literature