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BTB ACL Reconstruction
BTB ACL Reconstruction
The all-inside ACL reconstruction procedure is defined by the fact that sockets, not tunnels, are reamed on both the femur and tibia. The benefits of the all-inside approach, when compared against the traditional transtibial technique, are that more bone is preserved, incisions are smaller, and clinical outcomes are similar1. The all-inside ACL reconstruction technique grew significantly in popularity over the course of the past decade. This happened because adjustable loop buttons were developed. These buttons make the procedure less technically demanding than it previously was because surgeons can re-tension adjustable buttons, which eliminates the need for intraoperative calculations.
DePuy Synthes offers the RIGIDLOOP™ BTB Adjustable Cortical System which brings the benefits of adjustable fixation to BTB procedures. It is used for ACL reconstruction, All-Inside with both femoral and tibial fixation.
Suspensory BTB ACL Reconstruction - Dr. Karen Sutton, of Hospital for Special Surgery, performs the suspensory BTB ACL reconstruction using the RIGIDLOOP™ BTB Adjustable Cortical System.
Surgical Technique Steps
Graft Harvest and Preparation
Harvest a BTB graft according to surgeon preference. Please account for the following aspects of graft preparation:
Bone Plug: RIGIDLOOP™ BTB Adjustable Cortical System attaches to the bone plug using two sutures and two holes.
Bone Plug Length: A bone plug shorter than 20mm is easier to pass through the knee and into the socket. Overall Length: When the overall length of the graft exceeds 90mm, adapt your technique to account for this. There are three ways to adapt your technique to handle a longer graft: drill a longer femoral tunnel, drill a longer tibial tunnel, or manage excess graft outside the tibial tunnel.
Use a sagittal saw and rongeur to cut and shape the femoral and tibial bone plugs.
Use a rongeur to bullet the femoral bone plug. Drill two 1.5mm diameter holes on the femoral side bone plug.
Drill two 1.5mm diameter holes on the tibial side bone plug. These holes will be used for traction sutures. The diagram shows holes drilled perpendicular to each other, but the orientation (and even number of holes) is a matter of surgeon preference.
NOTE: Adapt your surgical technique according to the length of the graft in order to be able to ensure its tensioning during the final fixation.
In the case of a significant graft length: Extend the femoral tunnel and/or the tibial tunnel.
Button Attachment to Femoral Side Bone Plug
Unpack a RIGIDLOOP™ BTB Adjustable Cortical System - Standard. Grasp it with two fingers, as shown, to avoid pulling the black relay loops out of the assembly.
Hold the preparation card flat against a table.
Insert the femoral bone plug flush against the graft clamp on the button’s preparation card. The drill holes must be oriented as shown.
Completely unravel one of the two white tensioning sutures. It doesn’t matter which side is chosen.
Using a suture passing device such as a CHIA PERCPASSER® Suture Passer or a free needle with kite, pass the white tensioning suture through the proximal bone plug hole and the opposing black relay loop.
Note: “Proximal” in this context means the bone plug hole that is closest to the button.
Pull the corresponding black relay loop gently in a plane horizontal with the graft. Exercise slight counter-tension on the white suture, and once the white suture has entered the splice in the button, apply slow lateral movements (“wiggles”) to the end of the temporary black relay loop. Do this until the suture has fully exited the splice.
Pull the tensioning suture to eliminate slack in the loop. Wind the excess length of the tensioning suture around the winder and wedge it in the notch to lock it.
Unwind the second white tensioning suture. Pass it through the distal drill hole in the opposite direction of the first tensioning suture. “Wiggle” it through the splice using the same technique utilized for the proximal suture.
Insert two sutures into the tibial bone plug drill holes. These sutures will be used to control placement of the tibial bone plug.
Femoral Socket Retrograde Reaming
Drill the femoral socket using the TWISTR™ Retrograde Reamer according to the IFU. Insert a relay suture using an outside-in suture passing pin.
Tibial Tunnel Reaming
Drill the tibial tunnel from the outside-in using a fluted reamer. Reamer size and tunnel location should be chosen according to surgeon preference.
Use a shaver or rasp to chamfer the edges of the socket entrance and ease bone block passage into the socket.
Graft Fixation on the Femur
Remove the RIGIDLOOP™ BTB Adjustable Cortical System and graft from the preparation card. Unwind all sutures from the button preparation card. Remove the button from the card by lifting up all the sutures. Pull on the femoral bone plug to remove it from the clip on the preparation card.
Gently pull on each of the two suture loops to lengthen the distance from the underside of the button to the beginning of the femoral bone plug to 6cm or more.
Mark the femoral socket length on the femoral side suture loop. This mark is an indication of where to flip the button.
Use the relay suture to pull the RIGIDLOOP™ BTB Adjustable Cortical System sutures through the femoral socket.
Pull the RIGIDLOOP™ BTB Adjustable Cortical System into the joint space. Pull lightly on the blue/white suture to position the button near the entrance of the femoral socket. Use the blue/white suture to pull the button through the socket, and lightly pull other sutures, as needed, to avoid tangles. Switching the arthroscope to the AM portal may allow for a clearer view of the button and may facilitate passage of the button and bone block into the femoral socket.
Flip the button by pulling on the green flipping suture.
Alternately pull on the green suture and the blue/white suture to confirm the button is on the cortex and has successfully flipped.
Throughout the process of flipping the button and testing for flip success, maintain counter tension on the graft to ensure the button stays on the cortex.
Pull alternately on the white tensioning sutures of the button until the bone plug is at the entrance of the femoral socket. Use a probe to help position the bone plug. When the bone plug is positioned to surgeon preference, alternately pull on the white tensioning sutures until the bone plug is fully seated in the femoral socket.
Fix the graft in place in the tibial tunnel using a MILAGRO® ADVANCE Interference Screw according to the IFU.
Cycle the knee and adjust button tension until satisfied with graft tension.
Remove the green and blue/white sutures from the RIGIDLOOP™ BTB Adjustable Cortical System. Cut the white tensioning sutures. Leave at least 6mm of tail, as this is essential for sustained tension.
Products Used in this Procedure
TWISTR™ Retrograde Reamer & Cruciate+ Instruments
MILAGRO® ADVANCE Interference Screw
CHIA PERCPASSER® Suture Passer
RIGIDLOOP™ BTB Adjustable Cortical System
MILAGRO™ Advance Interference Screw
SPEEDTRAP™ Graft Preparation System
Twistr™ Retrograde Reamer and CRUCIATE+ Instrument System
- Connaughton, A.J., et al. All-inside ACL reconstruction: How does it compare to standard ACL reconstruction techniques?. Journal of Orthopaedics 14 (2017) 241–246. March 2017.
Please refer to the instructions for use for a complete list of indications, contraindications, warnings and precautions.