All-Inside BTB ACL RetroConstruction

All-Inside ACL RetroConstruction™

with Bone-Tendon-Bone Grafts

Surgical Technique
GRAFT PREPARATION

mm
mm 25
25
m
40 m

5 mm

1 2

The overall length of the graft must be at least 5 mm shorter than the combined length of the femoral socket, intraarticular
space and the tibial socket (1). In the example above, this total distance = 90 mm. This allows adequate space for tensioning
of the graft (2).

30-45 mm
20 mm 20 mm
70-85 mm

Trim bone blocks to a 20 mm length for an overall graft

length of 85 mm or less. If the tendon length is over
45 mm long, it may be necessary to trim bone block shorter
than 20 mm. The femoral bone block should be 10 mm in
diameter. The tibial bone block should be tapered at the tip,
approximately 8 mm, and increase to 9 mm near the tendon.
Drill a 2.4 mm hole perpendicular to the cortex. Insert one
#2 FiberWire® through the tibial bone block. Through the
tibial bone block place a #2 FiberWire and a #2 TigerWire®
through the drill hole.
PORTAL CREATION
The lateral portal is placed in standard fashion along the
lateral edge of the patellar tendon. The medial portal
should be placed just medial to the patellar tendon and
inferior to standard position to facilitate femoral socket
preparation. Medial portal incisions may be oriented
horizontally to allow instruments to be moved in the
transverse plane.

FEMORAL SOCKET PREPARATION

4 5

Bring knee into 120˚ of hyperflexion and place the femoral “aiming” guide through the medial portal. Engage the posterior
cortex with the guide and assure proper angulation before placing a beath pin. Proper angulation will assure preservation of
the backwall and avoid backwall “blow-out”. After placing a beath pin, ream femoral socket to a 25 mm depth (for longer
grafts, it might be necessary to ream deeper to accommodate the graft length). Use a beath pin to pass a graft passing suture and
dock the suture in the femoral socket for later use during graft passing.
TIBIAL SOCKET PREPARATION

m
40 m
6 7
50 mm 50 mm

Place a RetroCutter® that is 1 mm larger than the tibial graft diameter onto the Constant Tibial Guide. “Retrodrill” the tibial
socket as deep as possible without violating the distal cortex. Example: If the distance between the tibial plateau and distal
tibial cortex is 50 mm, as read off the drill sleeve, then drill socket 40 mm deep. This will assure easy manipulation of the
RetroScrew® Driver and adequate space for graft tensioning. Clean the ACL stump off the anterior rim of the tibial socket
using a shaver and/or OPES® ablator.

8 9

Pass a looped Nitinol wire through the cannulated RetroDrill® Pin and into the joint. Remove the RetroDrill Pin.
Pass the RetroScrew Driver over the Nitinol wire and into the joint.
10 11

Angle the driver to “dilate” bone and create a path to the anterior edge of the socket. Remove the driver and use the looped
Nitinol wire to pass suture into the knee and out the tibial tunnel (11).

GRAFT PASSING

12 13

Retrieve both the femoral and tibial graft passing sutures out of the medial portal. A cannula may be used to avoid tissue
bridges. Using the tibial passing suture, tie a loop around a looped Nitinol wire. Place the graft sutures from the femoral end
of the graft into the femoral passing suture. Load the tibial graft sutures into the tibial passing suture loop.
GRAFT FIXATION

14 15

Pass the femoral end of the graft into place. Use the looped suture to pass the tibial graft sutures and wire into the tibia at
the same time. Pass tibial bone block into place while maintaining wire anterior in the socket. Hyperflex the knee and fix the
femoral side of the graft with a bio-interference screw, through the medial portal.

16 17

Pass the RetroScrew Driver over the Nitinol wire and into the joint. Remove the Nitinol wire and replace it with a FiberStick™.
Retrieve the FiberStick out the medial portal through a Shoehorn™ Cannula. Attach the RetroScrew, 2 mm smaller than the
socket diameter, to the FiberStick. Pass into the joint and load on the RetroScrew Driver. Cycle the knee while tensioning
the graft. Keep tension on the graft while the screw is inserted into the tibial socket. A RetroScrew Tamp may be used to ease
insertion of the screw. Backup fixation may be accomplished by tying the tibial graft passing sutures over a two-hole suture
button on the anterior cortex with a sliding knot.
All-Inside ACL Reconstruction - Advantages
• Reduces patient morbidity
• Reduces or eliminates soft tissue hematoma formation
• Smaller incisions improve cosmesis
• May simplify rehabilitation
• Reduced infection risk
• Anatomic socket creation without transtibial drilling restrictions
• Distal cortex maintained for simple, low profile backup fixation
• Proven joint line fixation increases graft stiffness
• Maintains joint distention throughout the procedure

Recommended Transitional Surgical Steps to Performing All-Inside Reconstruction Techniques

A RetroDrill may be used to create a complete tibial tunnel and may be the preferred technique before moving on to the
All-Inside ACL Reconstruction. The RetroScrew may also be used to fix the ACL grafts anatomically at the aperture of a full
tibial tunnel.

Step 1: Full tunnel “retrodrilling”

• Reduces fracturing of the tibial plateau as seen with standard tibial reamers
• Cuts cylindrical tunnels that are true to size
• Visualize tunnel diameter before drilling
• Constant Tibial Guide provides unparalleled accuracy

Step 2: RetroScrew aperture fixation with full tunnel

• Anatomic, aperture fixation increases graft stiffness
• Strong cortical fixation at the tibial plateau
• Promotes graft incorporation by sealing off the tibial tunnel from synovial fluid
 Ordering Information
Instrumentation:
RetroScrew Driver, thin AR-1586R
Constant Tibial Guide for RetroDrill, 52.5˚ AR-1775R
Drill Sleeve for Constant Tibial Guide for RetroDrill AR-1776R
Transtibial Femoral ACL Drill Guide (TTG), 4 mm,
for 6 and 7 mm drill holes, purple AR-1806
Transtibial Femoral ACL Drill Guide (TTG), 5 mm,
for 7 and 8 mm drill holes, red AR-1803
Transtibial Femoral ACL Drill Guide (TTG), 6 mm,
for 8 and 9 mm drill holes, green AR-1804
Transtibial Femoral ACL Drill Guide (TTG), 7 mm,
for 10 and 11 mm drill holes, gold AR-1801
Transtibial Femoral ACL Drill Guide (TTG), 8 mm,
for 12 and 13 mm drill holes, blue AR-1805
Cannulated Headed Reamers, 5 mm - 14 mm AR-1405 - 1414
Button Inserter AR-8923
Bio-Interference Screw Set AR-1901S
RetroScrew Tamp AR-1586S
RetroScrew Tamp, 90˚ AR-1586ST-90
Tunnel Notcher AR-1844
Graft Passing Cannula, 11 mm AR-1861

Disposables:
RetroCutter, 6 mm AR-1204R-06S
RetroCutter, 6.5 mm AR-1204R-065S
RetroCutter, 7 mm AR-1204R-07S
RetroCutter, 7.5 mm AR-1204R-075S
RetroCutter, 8 mm AR-1204R-08S
RetroCutter, 8.5 mm AR-1204R-085S
RetroCutter, 9 mm AR-1204R-09S
RetroCutter, 9.5 mm AR-1204R-095S
RetroCutter, 10 mm AR-1204R-10S
RetroCutter, 10.5 mm AR-1204R-105S
RetroCutter, 11 mm AR-1204R-11S
RetroCutter, 12 mm AR-1204R-12S
RetroDrill Guide Pin, 3 mm, cannulated (for RetroCutters) AR-1250RP
All-Inside Disposables Kit AR-1587S
Allograft Plug Delivery Sleeves, 7 mm - 11 mm AR-1981BI-07 - 11

Implants:
Tibial:
RetroScrew, 7 mm x 20 mm AR-1586RB-07
RetroScrew, 8 mm x 20 mm AR-1586RB-08
RetroScrew, 9 mm x 20 mm AR-1586RB-09
RetroScrew, 10 mm x 20 mm AR-1586RB-10
Suture Button, 3.5 mm AR-8920
Suture Button, 7.5 mm AR-8922
Femoral:
Sheathed Bio-Interference Screw, 7 mm x 23 mm AR-1370B
Sheathed Bio-Interference Screw, 8 mm x 23 mm AR-1380B
Sheathed Bio-Interference Screw, 9 mm x 23 mm AR-1390B
Sheathed Bio-Interference Screw, 10 mm x 23 mm AR-1400B

Suture:
#2 FiberWire, 38 inches, 2 strands (1 blue, 1 white/black), qty. 12 AR-7201
FiberStick, #2 FiberWire, 50 inches (blue) one end stiffened, 12 inches, qty. 5 AR-7209
#2 FiberLoop w/Straight Needle, qty. 12 AR-7234

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.

U.S. PATENT NOS. D378,780; 5,211,647; 5,320,626; 5,350,383; 5,425,733;

6,461,373; 6,716,234; 7,029,490 and PATENTS PENDING
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Copyright Arthrex Inc., 2007. All rights reserved. Toll-Free: 1-800-934-4404. LT0198A