Surgical Technique

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Anatomic Cruciate Reconstruction Solutions, from ConMed Linvatec.

Precise | Flexible | Intuitive

Surgical Preparation
Before the arthroscopic ACL repair can begin, all meniscal pathology should be identied and repaired as necessary. Adequate visualization should be ensured by removing any fatty tissue that could interfere with the viewing of the ACL anatomy. The medial portal is generally used for visualization in this technique with instrument access to the femoral condyle being achieved through an accessory medial portal approach.
Surgical Technique described by John Xerogeanes, MD, Chief of Sports Medicine Emory Orthopaedics and Spine Center Atlanta, GA

Anatomic Drilling and xation system options:

Extracortical Fixation
Pre-stretched Dyneema* Loop Prevents Graft Creep HiFi (High Strength) Suture Included

Anatomic Single or Double Bundle

Proprietary roprietary Self-Reinforced PLA with TCP Particles Proven Osteoconductivity Proven Tri-Lobe Driver Interface Wide Range of Sizes Available (5.0mm to 11.0mm) diameters

Depth Measuring Drill Bit Technique

This product contains Dyneema Purity. Dyneema Purity is a registered trademarkof Royal DSM N.V.

Bulbous Eye for Central Seating in Tunnel 15 to 60mm Loop Lengths

Eccentric Mono-uted Drill Bit

Mono-uted to Protect Cartilage When Sliding Past Medial Femoral Condyle (Medial Portal Approach) Single Flute Allows for Smaller Skin Incision 5.5 to 13.0mm sizes

Portal Creation and Incising

Arthroscopic surgical approach for anatomic ACL reconstruction requires three portals: an anterolateral, an anteromedial, and an accessory anteromedial. The standard anteromedial portal will be used for arthroscopic visualization and should be placed close to the patellar tendon and adjacent to the inferior pole of the patella. The accessory anteromedial portal will be used for drilling and should be lower and more medial than the anteromedial portal.

Anteromedial (AM)

Anterolateral (AL)

Accessory Anteromedial (AAM)

Step One:
With the surgical markings in place, incise the anteromedial and anterolateral portals. Insert a ConMed Linvatec shaver to excise any remaining ACL tissue.

Step Two:
Creation of the accessory anteromedial portal is made under direct visualization with the arthroscope placed in the anterolateral portal looking medially. With the knee exed at 90 degrees, palpate the medial joint line. Under direct visualization, insert a needle just anterior to the medial femoral condyle, directed towards the intercondylar notch. The needle should be above the medial meniscus to avoid damage. Advance the needle to conrm access to the femoral footprint of the ACL. Using an 11 blade, incise the skin making sure to orient the blade away from the femoral condyle to prevent damaging the articular surface.

Step Three:
Switch the arthroscope to the anteromedial portal. Mark the center of the femoral ACL footprint using a microfracture awl in the AAM Portal.

Step Four:
Once marked, use the Bullseye Native Footprint Ruler to assess the footprint of the native ACL stump.

Positioning and Drilling of the Femoral Tunnel

With the ACL footprint identied and the center marked, insert the Bullseye Femoral Footprint Guide into the Accessory Anteromedial portal with the knee exed at 90 degrees.

Step One:
Place the guide at the center of the ACL Footprint. Advance the Pin a few millimeters to notch the bone. Then check to ensure that the pin correlates to the mark made earlier.

Step Two:
Hyperex and elevate the knee and then advance the guidepin to the lateral cortex. Note the aperture to cortex length, then advance out of the skin.

Step Three:
Use a twisting motion to remove the Femoral Footprint Guide.

Step Four:
Insert the mono-uted Sentinel Drill Bit over the guide pin through the accessory anteromedial portal with the cutting edge facing away from the femoral condyle and advance the Drill Bit to the femoral ACL footprint.

Step Five:
Using a piston-like back and forth motion, drill the femoral socket to the desired depth cautiously to prevent blow out of the lateral femoral cortex.

Step Six:
Keeping the hand off of the trigger, slide the Sentinel Drill Bit past the medial femoral condyle and out of the portal, making sure to keep the blade oriented away from the condylar surface.

Step Seven:
Use the XO Button Drill Bit to drill the femoral channel. Advance the drill bit through the lateral cortex. Using the XO Button Drill Bit as you would use a standard depth gauge, manually pull back on the bit to hook the head of the drill bit on the external femoral cortex to conrm the aperture to cortex length.

Step Eight:
Remove the XO Button Drill Bit leaving the graft passing guide pin in place. Place the two free ends of the #2 passing suture through the eyelet of the guide pin. Then, pull the guide pin through the femur laterally, making sure to keep a nger in the suture loop to prevent it from being pulled into the knee joint.

Step Nine:
Once the suture ends are retrieved laterally, pull the looped end of the suture all the way to the entrance of the femoral tunnel.

Tibial Tunnel Positioning and Drilling

Switch the arthroscope to the anterolateral portal. Next, insert the Lightwave Ablator into the anteromedial portal to mark the center of the tibial ACL footprint.

The center of the footprint is referenced off the Posterior aspect of the Anterior horn of the Lateral Meniscus.

Step One:
Set the angle of the Pinn-ACL Guide to 55 degrees. Insert the tip into the anteromedial portal, placing the tip of the guide into the center of the tibial ACL footprint. Next, advance the external guide sleeve ush to the anterior tibial cortex.

Step Two:
Using the ConMed Linvatec M-Power 2 handpiece and pin-driver attachment, advance the guide pin until it meets the point of the guidearm. Then, depress the Pinn-ACL drill guide lever to remove the sleeve. Remove the Pinn-ACL guide from the guide pin and joint.

Step Three:
Place a curette over the point of the guide pin to protect against inadvertent advancement when drilling. Use the appropriate size Badger or Sentinel Drill Bit to drill the tibial tunnel.

Tensioner Breakaway Pins Placement and Graft Passage

Using the appropriate size SE Graft Tensioner Drill Guide, place the guide in the tibial tunnel and position two Breakaway pins and then remove the guide.

Step One:
Next, place a probe into the accessory anteromedial portal to bring the loop of the suture into the joint. Retrieve the loop through the tibial tunnel using Suture Retrieval Forceps.

Step Two: One:

With the suture loop exposed externally, load the suture strands of the XO Button loaded graft into the passing suture loop and pull them through the femoral tunnel, making sure to keep the graft construct outside of the tibia.

Step Three:
3
Pull the XO Button loaded graft into the joint and through the femur while hyperexing and elevating the knee to ease the graft passage. Finally, ensure that the XO Button has ipped and is seated.

Graft Tensioning and Fixation

Step One:
Load the SE Graft Tensioner Suture Separator. Spread the whip-stitch strands radially as you load the SE Graft Tensioner.

Step Two:
Tying the appropriate bundle strands to the left and right tensioner wheels allows the bundles to be individually and accurately tensioned. Apply the desired graft tension and then cycle the knee to alleviate laxity. Hold the knee at fteen degrees and set the desired nal tension.

Step Three:
Next, load the appropriately sized Matryx Interference Screw onto the Tri-Lobe driver. Ensure that the knee is in fteen degrees of exion. Advance the Linvatec BioScrew HyperFlex Guidewire into the tibial tunnel and in the center of the four graft bundles. Load the Matryx Interference Screw and driver on to the guidewire and advance it through the tensioner and into the tibial tunnel until it is ush with the external tibial cortex.

Final Step
Lastly, remove the SE Graft Tensioner and Breakaway pins and follow the normal procedures to close the incisions. Note the anatomic position of the nal graft placement. Performing an anatomic ACL reconstruction using the AAM portal provides improved rotational stability compared to a non-anatomic reconstruction. Ranging the knee through exion and extension no graft impingement is observed. Additionally, with this technique a notchplasty is generally not needed except if an unnatural anatomy such as an A shaped intercondylar notch is present. These are a few of the numerous advantages of using the ConMed Linvatec Bullseye Anatomic Cruciate Reconstruction System, and the anatomic single bundle technique.

Ordering Information
Bullseye Femoral Footprint Guide Description Cat. No. 5mm ......................................................... SB5000 6mm ......................................................... SB6000 7mm ......................................................... SB7000 8mm ......................................................... SB8000 9mm ......................................................... SB9000 10mm ..................................................... SB10000 11mm ......................................................SB1 1000 Bullseye Femoral Footprint Ruler Description Cat. No. Bullseye Femoral Footprint Ruler ..................... RL1000 Sentinel Drill Bits (sterile, 4 per box) Unique mono-uted design allows blade to be pointed away from vital structures (condyles, PCL). Especially useful with a medial portal approach. Description Cat. No. 5.5mm x 9 in. ..............................................S8555 6.0mm x 9 in. ..............................................S8560 6.5mm x 9 in. ..............................................S8565 7.0mm x 9 in. ..............................................S8570 7.5mm x 9 in. ..............................................S8575 8.0mm x 9 in. ..............................................S8580 8.5mm x 9 in. ..............................................S8585 9.0mm x 9 in. ..............................................S8590 9.5mm x 9 in. ..............................................S8595 10mm x 9 in. ...............................................S8510 10.5mm x 9 in. ..........................................S85105 11mm x 9 in. ...............................................S8511 11.5mm x 9 in. ..........................................S85115 12mm x 9 in ................................................S8512 12.5mm x 9 in. ..........................................S85125 13mm x 9 in. ...............................................S8513 Pinn-ACL Cruciate Guide System (includes ACL Guide Arm and Pin-Sleeve) 5, 6 ....8731 ACL Pin-Sleeve (replacement sleeve for 8731) ......8719 Accessories Description Cat. No. 14 in. High Strength Guide Pin, 2.4mm dia. ...................................................9744 Graft Passing Guide Pin, 2.4mm dia. ................................................ C8675 Matryx Osteconductive Bioabsorbable Interference Screw (SR-96L/4D PLA with -TCP) The most advanced biocomposite on the market! Combining proprietary Self-Reinforced technology with proven osteoconductivity. Description Cat. No. 5.0mm x 15mm ..................................... 235015T5 5.0mm x 20mm ..................................... 235020T5 5.0mm x 25mm ..................................... 235025T5 5.0mm x 30mm ..................................... 235030T5 5.5mm x 15mm ..................................... 235515T5 5.5mm x 20mm ..................................... 235520T5 5.5mm x 25mm ..................................... 235525T5 5.5mm x 30mm ..................................... 235530T5 6.0mm x 15mm ..................................... 236015T5 6.0mm x 20mm ..................................... 236020T5 6.0mm x 25mm ..................................... 236025T5 6.0mm x 30mm ..................................... 236030T5 6.5mm x 15mm ..................................... 236515T5 6.5mm x 20mm ..................................... 236520T5 6.5mm x 25mm ..................................... 236525T5 6.5mm x 30mm ..................................... 236530T5 7.3mm x 20mm ..................................... 237020T5 7.3mm x 25mm ..................................... 237025T5 7.3mm x 30mm ..................................... 237030T5 8mm x 20mm ........................................ 238020T5 8mm x 25mm ........................................ 238025T5 8mm x 30mm ........................................ 238030T5 9mm x 20mm ........................................ 239020T5 9mm x 25mm ........................................ 239025T5 9mm x 30mm ........................................ 239033T5 9mm x 38mm ........................................ 239038T5 10mm x 25mm ...................................... 231025T5 10mm x 33mm ...................................... 231033T5 10mm x 38mm ...................................... 231038T5 11mm x 25mm ...................................... 231125T5 11mm x 33mm ...................................... 231133T5 11mm x 38mm ...................................... 231138T5 XO Button (with HiFi) Contains pre-stretched Dyneema loop, and Hi-Fi high strength suture. Easy to ip and re-position if required. Description Cat. No. 15mm Continuous Loop ................................. T5015 20mm Continuous Loop ................................. T5020 25mm Continuous Loop ................................. T5025 30mm Continuous Loop ................................. T5030 35mm Continuous Loop ................................. T5035 40mm Continuous Loop ................................. T5040 45mm Continuous Loop ................................. T5045 50mm Continuous Loop ................................. T5050 55mm Continuous Loop ................................. T5055 60mm Continuous Loop ................................. T5060 XO Button Instrumentation Description Cat. No. XO Button Drill Bit ........................................ C8590 XO Button Holder ....................................... PS8834 XO Button Graft Passing Guide Pin .................. C8676 EL Depth Probe ..........................................21.1001 SE Graft Tensioner A unique system that enables load equalization over two soft-tissue grafts. Enables in-situ graft pre-conditioning, and central screw insertion. Description Cat. No. SE Graft Tensioner ........................................ C9050 SE Graft Tensioner Drill Guide, 6mm................ C9051 SE Graft Tensioner Drill Guide, 8mm................ C9052 SE Graft Tensioner Suture Separator................. C9053 SE Graft Tensioner Breakaway Pins with Graft Tension Calculator ................................ C9054 SE Graft Tensioner System Sterilization Tray ....... C9055 Screw Pick-up .................................................8606 Literature Description Cat. No. Anatomic Single Bundle ACL Reconstruction Technique Video and Animation .................. DVD0029 Anatomic Single Bundle Printed Technqiue .....CST1031 XO Button Surgical Technique Video........... DVD0025 SE Graft Tensioner Surgical Technique Video ....... CD20 SE Graft Tensioner Illustrated Guide .................. VT125

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This product contains Dyneema Purity. Dyneema Purity is a registered trademarkof Royal DSM N.V.

2009, Linvatec Corporation, a subsidiary of CONMED Corporation, 11/2009, CST 1031