Aesculap® POSITION ACL
The anterior cruciate ligament reconstruction system
Operating technique
Aesculap Orthopaedics
2
Table of contents
POSITION ACL
Anterior cruciate ligament reconstruction system
4
Operating technique
1 | Transplant selection
6
2 | Transplant harvesting
8
3 | Drill channels
10
4 | Transplant preparation
15
5 | Transplant insertion and fixation
24
6 | Double Bundle Technique
27
7 | Postoperative Care
31
Implants
40
Basic instrument set
Femoral aiming devices
43
Tibial aiming devices
44
Instruments
45
Basic Instrument Set
Suture Board
46
Drills
47
Instruments
Dilators
48
Instruments
50
Storage
Additional instruments
51
Recommended Containers
52
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POSITION ACL – anterior cruciate ligament reconstruction system
FR507M
FO010R
FO029
4
POSITION is a system for minimally invasive arthroscopic anterior cruciate ligament reconstruction.
The surgical procedure allows for free selection of the
transplant.
With the POSITION Basic Instrument Set, positioning
of drill channels and fixation of the transplant are
performed without a femoral incision.
The POSITION Suture Board facilitates and supports
the transplant preparation.
The freedom of selection of the transplant together
with the special POSITION titanium implants – the
Suture Plate (femoral) and Suture Disk (tibial) – represent an important advance compared to fixation devices such as intra- or extra-articular screws or staples.
With correct assemply, transplant, fixation at a distance from the joint obtains the same results as fixation close to the joint. Fixation at a distance from the
joint also significantly facilitates any later revision.
The POSITION Implantation Set also makes the operation easier. It contains all necessary implants and
suture materials for this operating technique. These
tare perfectly matched to one another – and are simply presented in a single sterile pack – for outstanding
results with much less effort.
POSITION Suture Plate
Femoral transplant fixation
Less invasive – no lateral incision
Easy revisions – no intra-articular implants
Free selection of transplants with high rupture
resistance
Suture Plate
Suture Plate mit Endless Loop
POSITION Suture Disk
Tibial transplant fixation
Better transplant integration attributable to the
central position of the tendon in the drill channel.
Less bleeding due to distal covering of the drill
channel.
Implant removal unnecessary, because of the flush
fit of the Suture Disk on the bone surface and
knots recessed in the implant. Defined reproducible tightening of the transplant with the
POSITION Twister.
An important feature in the double bundle (DB)
technique since each bundle must have a different
transplant tension.
POSITION Implantation Set
Simple sterile setup
All necessary components from one source
Matching suture materials and implants
Suture materials specific for single- and doublebundle technique
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Operating technique
1 | Transplant selection
Two innovations have improved the results of ACL reconstruction surgery: the introduction of arthroscopic
operating techniques and targeted, early-functional
postoperative therapy with immediate full extension.
For a long time patellar tendon surgery was considered
the ”gold standard” in ACL surgery. Femoral fixation
with the Suture Plate enables the use of the semitendinosus tendon with a quadruple technique. This
means that the gracilis tendon can be preserved for
the most part. The semitendinosus tendon alone is
suitable for performing the double bundle technique,
involving the gracilis tendon only if necessary. The
quadriceps tendon is now being increasingly used for
revision transplants.
To assist in the selection of the appropriate transplant,
the advantages and disadvantages of the different
tendon types are listed below.
Patellar tendon
Advantages
Variable transplant width
Easy preparation
Stable primary fixation
Preservation of active internal rotation
Slow, clinically proven ligamentation
Good long-term results (published)
Weakening of the antagonist
Disadvantages
Problems from donor site defects
Impairment of the extensors
Approximately 15 % persistent quadriceps function loss
Anterior knee pain
Problems with kneeling activities
Slow ligamentation with transplant maturation
Very stiff transplant
Increased risk of cyclops syndrome and arthrofibrosis
Risk of patella fracture
Skin incision in mobile areas, tendency for keloid
formation
Drill channels are completely filled out with bone
material, but not with the tendon; synovial fluid can
enter the drill channels and cause cystic expansion
Double bundle technique not possible
Semitendinosus tendon
Advantages
Smaller skin incision in non-mobile area
No impairment of extensors
No problems associated with kneeling
Good blood supply to the strands
Elasticity similar to healthy cruciate ligament
Disadvantages
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Impairment of active internal rotation
Bleeding from transplant donor site
No published long-term results on
ligamentation and remodelling processes
Longer preparation time
Weakening of the agonist
Quadriceps tendon
Advantages
Very thick long transplant
Variable transplant widths and lengths
Active internal rotation preserved
Weakening of the antagonist
Proven revision transplant
Scar distortion can be compensated with
the quadriceps muscle
Implantation technique similar to that
of the semitendinosus tendon
The patellar tendon and semitendinosus tendon make
good transplants for the anterior cruciate ligament.
However, the semitendinosus tendon is preferred in
the following cases:
Patients involved in frequent kneeling activities
Patella infera
Morbus Osgood Schlatter disease
Tibial intramedullary nailing
Injury to the patella or patellar tendon
Regarding alternative operating techniques without
lateral incision, the femoral block technique and
central femoral fixation with an interference screw
are very common. For safety reasons, a distance of
1 mm to 2 mm to the posterior bone wall must be
kept to prevent a bone break-through (“blow out”)
caused by the fixation. Therefore, there is a tendency
to apply the drill channels too far towards ventral
when implanting the interference screw.
Disadvantages
Second ventral skin incision necessary
No published long-term results on ligamentation
and remodelling processes
Double bundle technique not possible
Other possible complications:
Damage to the transplant
Screw or bone defect following a revision
Revision often necessitates a two-stage intervention.
Initially, the hole left by the interference screw is
filled out with a corticospongiosa bone chip. The
actual stabilization is carried out in the second step.
The operating technique using the POSITION ACL
Reconstruction System, as described below, takes into
account the above advantages and disadvantages:
free choice of transplant, drilling technique without
lateral incision and extra-articular implants for transplant fixation with easier revision should this become
necessary.
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Operating technique
2 | Transplant harvesting
Semitendinosus tendon (STT)
The skin incision to harvest the semitendinosus tendon must be at least 3-4 cm long. It begins medially
close to the end of the tibial tuberosity.
When preparing the subcutaneous tissue, care must
be taken to avoid injury to the aponeurotic sartorius
tendon as this is sometimes only marginally thicker
than the subcutaneous fasciae.
The aponeurosis of the sartorius tendon is located
above the gracilis and semitendinosus tendon. The
gracilis tendon can be palpated as the thicker tendon
of the pes anserinus. The semitendinosus tendon lying
inferiorly is harvested. The gracilis tendon is harvested
only in the event of inadequate transplant quality.
The gracilis tendon is retracted using a Kocher clamp
in order to identify the gracilis tendon and the STT
from proximal. The STT is luxated with a small, 90°curved Overholt clamp and armed with a suture.
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The STT is taken out distally by taking both the periosteum and the Sharpey’s fibres up to the tibial crest below the tubercle. This is to obtain an additional length
of approximately 2 cm. Also, the periosteum flap will
improve tendon attachment in the tibial drill hole.
Note
For easier identification, the sartorial fascia, proximal to the gracilis tendon, can be split for 3 cm to
4 cm along the length of the tendon.
To strip the tendon, the standard procedure is to use a
6 mm Tendon Stripper (FO023R). With thicker tendons,
the Tendon Stripper FO024R, which has an internal
diameter of 7 mm, can be used. Both instruments
have a measuring scale on the shaft, which allows for
monitoring the tendon length already harvested in
the stripping process.
Before stripping begins, it is important to sever the
connections with the medial head of the gastrocnemius, the gracilis tendon, and the semimembranosus
tendon with a sharp cut. Otherwise, the tendon stripper can slip and destroy the transplant. Harvesting of
the semitendinosus tendon is more manageable if
good muscle relaxation is ensured.
The harvested tendon is usually between 24 cm and
34 cm in length. The gracilis tendon should only be
used in exceptional circumstances (if the tendon length
is less than 24 cm or if the posterolateral bundle does
not meet the minimum 5- mm diameter required), as
this may result in excessive functional impairment of
the pes anserinus.
An additional periosteal flap is grafted from below
the STT donor area. This will later be sutured into the
femoral loop of the transplant.
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Operating technique
3 | Drill channels
Prior to the actual ACL reconstruction, meniscus and
cartilage pathologies are treated arthroscopically, if
necessary. As the second step of the preparation, any
residual scar tissue should be removed from the fossa.
When doing this, as many structures as possible should
be preserved to improve orientation and preserve proprioceptive sensors.
Tibial drill channel
Single bundle techniques
The remaining distal stump of the anterior cruciate
ligament is used as an orientation point for positioning
the tibial drill hole.
Other reference points are:
Distance from posterior cruciate ligament
Medial tibial spina
Anterior horn of the lateral meniscus
Using the Tibial Aiming Device (FR500M), a 2.5- mm
Kirschner wire (LX045S) is inserted. The distance of the
hook of the Tibial Aiming Device from the K-wire exit
point is 5 mm.
With the K-wire in place, the aiming device is removed
and the tibial channel is drilled out step by step, using
a series of cannulated drills (FR515R - FR521R)
according to the measured total transplant thickness.
Drilling in stages allows subtle corrections to the
channel position and reduces thermal damage to the
spongiosa.
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Patellar tendon transplant
Initially, the tibial channel should be applied with a
6- mm trephine in order to obtain a cylinder of spongiosa, which can be used to fill the defects left at the
donor site in the patella and tibial tuberosity.
Next the channel is drilled open to the required
thickness, using cannulated drills as described above.
Note
For very long transplants, the drill channel should
not be too vertical, in order to avoid damage to the
pes anserinus. Such damage would rule out later
revision using the semi-tendinosus tendon.
Femoral channel
Single bundle technique
Position
In the single bundle technique, the femoral drill
channel is positioned using a Femoral Aiming Device
(FO006R, FO007R, FO010R, FO012R, FO013R). The offset hook of the aiming devices is set at 3 mm to 7 mm
diameter, depending on the transplant thickness.
e.g. 5 mm
Transtibial introduction of the aiming device should
be avoided, since the target position of the femoral
drill channel on the lateral wall of the fossa (clock
time 10.30 for the right knee, 1.30 for the left) cannot
be reached. If the placement of the tibial drill channel
is too horizontal, a risk is created of damaging the
inner ligament or the cartilage on the medial tibial
head. With anteromedial introduction of the aiming
device, the knee flexion must be between 110° and
120°. It is common for the Hoffa fat pad to slip into
the arthroscopic field during the procedure, making
it necessary to use the skin surface to read the drill
scale.
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Operating technique
3 | Drill channels
Note
In the case of anteromedial drill channel positioning, the femoral drill channel is sometimes very
short. If the transplant thickness is greater than
6 mm, a test channel of the appropriate insertion
depth should be made as a precaution, to prevent
perforation of the opposite cortex with a thicker
drill, which would hinder the application of the
Suture Plate fixation method.
The femoral aiming device is hooked in an appropriate
position on the posterior fossa wall and the drill pin/
pull-out pin (FO025R, FO036R) is inserted until it
perforates the opposite lateral cortex.
Note
As an alternative to step-by-step drilling, dilators
may be used to compress the drill channel. This
helps prevent drilling-related heat necrosis, while
compression of the spongiosa will also contribute
to the tendon healing process.
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Measuring drill depth “B”
Total graft length (e.g. 70 mm)
To determine the drill depth “B”, the length of the
prepared graft needs to be known. This graft is usually
between 6 cm and 8 cm long.
Femoral “Af”
20 mm
Intra-articular
24 mm
Tibial “At”
26 mm
First, the transplant portion inside the femoral drill
channel is determined (length “Af”). This is calculated
from the total transplant length and the individual
intra-articular length set by the surgeon. It is usually
about 22 – 24 mm. In most cases, 20 mm of the graft
is placed in the femoral channel to enable placement
of the longer graft length in the tibial channel.
Exceptions include very long grafts in small knee joints
(22 mm femoral insertion depth) and graft lengths
shorter than 70 mm (18 mm femoral insertion depth).
Intra-articular placement of the suture material,
how-ever, must be avoided.
Example
“B”
70 mm (graft length)
– 24 mm (intra-articular length)
= 46 mm
= 20 mm (tendon portion “Af” in femoral channel)
= 26 mm (tendon portion “At” in tibial channel)
"C"
m
m
10
Then drilling depth “B” can be determined, which
requires at least a 10- mm flip radius of the POSITION
Suture Plate to be added to the length of the tendon
portion within the femoral channel “Af”.
“Af”
Example
20 mm (tendon length “Af“in the femoral channel)
+ 10 mm (flip radius)
= 30 mm (minimal drilling depth “B“)
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Operating technique
3 | Drill channels
There must be at least 18 mm of tendon in both
femoral and tibial channels to ensure adequate tendon
ingrowth. When using the patellar tendon, at least the
length of the bone block should be sunk into the drill
channels.
The drilling depth “B” is drilled under arthroscopic control, using the reamers with scale markings (FO081R –
FO093R), according to the measured transplant thickness. (If visualisation is poor, read the scale on the
skin.)
Completion of the femoral drill channel
The penetration channel, through the opposite lateral
cortex “C”, is applied with a 4.5- mm reamer (F0026R)
in such a way that the Suture Plate can be pulled
through completely. Preferably, to reduce the overall
operation time, the tendon should be prepared and
armed with holding sutures by an additional surgical
team.
Note
To avoid penetration of the lateral cortex, the last
10 mm of the half channel should be drilled by hand,
without motor power.
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4 | Transplant preparation
Preparation and arming of the semitendinosus
tendon
tendon clamps
work surface
scales
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Operating technique
4 | Transplant preparation
Preparation of the semitendinosus tendon
After harvesting the transplant, the useful length of
the semitendinosus tendon is measured along the
Suture Board (FO029). A curette or rasp is used to
remove muscle tissue still attached to the proximal
aponeurosis.
When the semitendinosus is used as a single strand,
previous experience has shown that it is too weak for
the long term. It tends to stretch, especially after 2 to
5 years. Thus it is inadequate for cruciate ligament
reconstruction. For this reason at least three strands
of semitendinosus tendon are used today and where
possible four. In the quadriceps technique a minimum
length of 24 mm is required to support a transplant
length of 6 cm. If the useable tendon material is shorter than 24 cm, the triple technique must be used
instead or a gracilis tendon graft must also be added.
For the quadruple M technique, the entire tendon
graft is arranged in an M-shape with four legs of
equal length.
For the triple S technique, the full length of tendon is
arranged in an S-shape with 3 legs of equal length.
Quadruple M
technique
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Triple S
technique
The graft thickness is measured with the measuring
block (FO038R) and thereby the diameter of the drill
channels can be set. Each end must be measured
separately since the femoral drill channel is often 0.5 –
1.0 mm thinner than the tibial because of the compression procedure used.
Arming the semitendinosus tendon
The POSITION Implantation Set includes the implants
as well as all necessary suture materials for the
operating technique described below.
The tendon grafts sections for the quadruple technique
or the triple technique are clamped under tension in
the detachable atraumatic tendon clamp on the
Suture Board. The free tendon ends are armed, under
light tension, with Premicron®, USP2, HRT 37.
15 mm
When arming the tendon, care must be taken that approximately 15 mm of each tendon end is held by the
sutures. The loops must be tightened very tightly. The
distance between the loops must be large enough to
allow attachment of the tendon into the bone channel.
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Operating technique
4 | Transplant preparation
The strip of periosteum harvested from the STT donor
site is sutured into the femoral loop of the transplant,
close to the aperture, to block the channel so that an
additional piece of periosteum is present in the femoral
channel. This will improve the ingrowth of the tendon
into the femoral bone channel and help prevent penetration of synovial fluid.
Once the tendon graft has been armed with sutures, it
should be re-measured since its thickness may increase
because of suturing, especially in the tibial channel.
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Pre-tensioning the transplant
Pre-tensioning device, femoral
Suture Plate holder
Ruler for knot length measurement
Suture Disk holder
Pre-tensioning device, tibial
Suture holder
Spring scale
Spring
Slider
The tendon clamps are replaced with the pre-tensioning devices and the implant holders.
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Operating technique
4 | Transplant preparation
Arming the implants
In the quadruple strand technique, the graft ends are
brought together to form a loop and the Surgical Loop
or Dagrofil® USP6 is threaded through this and doubled.
This is then fed through the inner two holes of the
Suture Plate so that the ends lie between the graft
and the Suture Plate.
Dagrofil® USP6
The outer two holes are threaded with two further
sutures (a pull and a flip suture). The pull suture should
be strong enough to resist breaking since it is often
very difficult to pull the transplant through to the
bone channel if the compression technique is used.
Dagrofil® USP2
The Suture Plate threaded with sutures is inserted into
the Suture Plate holder. The Surgical Loop is fixated
with a clamp after pre-tensioning.
The tibial sutures are fed through the two holes of the
Suture Disk, wrapped around the suture holder, and
secured with the mosquito clamp (BH104R).
The required pre-tensioning can be adjusted by pressing the spring on the tibial pre-tensioning device and
fixating the slider in the appropriate position. The
tension can be read from the spring scale.
Both tendon types require pre-tensioning of the complete system for about 5 minutes, at a defined tension.
The transplant and the sutures will be stretched and
the knots will settle down.
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„G
Measuring knot length “K”
“(
50
mm
)
After pre-tensioning of the transplant, the required
knot length is measured and fixed.
„K
“(
30
mm
)
„A
f“
(20
mm
)
For knot length “K”, which defines the distance
between the Suture Plate and the implant, the total
length “G” of the femoral drill channel is measured
using the Depth Probe (FO027R). From this, the
transplant length “Af“ within the femoral channel is
subtracted.
Example
50 mm (total length “G“)
– 20 mm (tendon length “Af“ in the femoral drill
channel)
„G“, 50 mm
= 30 mm (knot length “K“)
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Operating technique
4 | Transplant preparation
The knot length “K” (example: 30 mm) is adjusted on
the ruler of the femoral implant holder of the Suture
Board; the distance is fixed by knotting the Surgical
Loop under tension. In this case, the reading is not
taken directly from beneath the Suture Plate, but in
relation to a preset zero point.
Suture Plate
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Insertion marking “M”
“G“
“K“
“A
f“
(2
0m
“M
30
m)
“(
Before insertion, an entry mark is made on the transplant. This mark indicates, intra-articularly, when the
Suture Plate has been pulled out of the opposite lateral
cortex by a sufficient distance so that it can be flipped.
This prevents the Suture Plate from being pulled too
far into the muscles and during the plate withdrawal
avoids the risk of trapping tissue between the implant
and the bone, which could lead to a loss of cortical
fixation.
mm
)
The position of the transplant marking is determined
by the length of transplant in the femoral drill channel
(“Af”), plus an extra 10 mm to allow for the Suture
Plate to be turned (flipped) after it has emerged from
the femoral cortex. The insertion mark “M“ corresponds
to the minimum drilling depth “B“.
Example
20 mm (tendon length “Af“)
+10 mm (flip radius)
“Af”
10 mm
= 30 mm (marking “M“)
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Operating technique
5 | Transplant insertion and fixation
Inserting the transplant
Single bundle technique
The pull and flip sutures are threaded through the eye
of the pullout pin (FO025R, FO036R).
Note
Alternatively, the eye of the pullout pin can be
armed with a suture loop at the distal end. This will
make it easier to thread the pull and flip sutures.
Since the transtibial approach to the femoral channel is
not an option, direct pulling of the pullout pin through
the tibial and femoral channels is not possible. The
pullout pin therefore must first be introduced through
the anteromedial portal of the arthroscope and the
femoral drill channel, inserted percutaneously, and
pulled through until the suture loop projects from the
channel. A micro-forceps (OG335R) is introduced
through the tibial channel and the suture is guided out
transtibially. Care must be taken that the suture loop is
long enough. The pull and flip sutures are placed in
the suture loop in such a way that the Suture Plate is
vertical when guided by the pull sutures.
The transplant is pulled through until the mark on the
tendon emerges at the exit of the femoral drill channel.
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Femoral fixation
By pulling the flip suture, the Suture Plate is positioned across the drill hole. The graft is pulled back
into the joint by 10 mm, so that the Suture Plate
rests flat on the femoral cortex.
Next, the graft is pulled distally by the tibial sutures
so that the Suture Plate rests flat on the cortex.
Then the knee is moved through flexion and extension several times while keeping the graft under
high tension.
Tibial fixation
Prior to tibial fixation, the surface on which the
Suture Disk (FO035T, FO034T) will be supported is
exposed.
Tibial fixation is executed using the Suture Disk.
The transplant is tensioned and the distal sutures
are tied under tension.
The second knot is applied using a knot pusher
(FO028R). This ensures the secure fixation of the first
knot and prevents knot slipping and the consequent
major loss of implant tension.
25
Operating technique
5 | Transplant insertion and fixation
Reducing residual laxicity
The leg is moved through flexion and extension several
times and kept in hyperextension. The transplant will
settle finally in this process and the tibial knotting
will yield slightly. The residual laxicity caused by this
effect is eliminated by twisting the Suture Disk, using
the Twister (FO037R). The tibial sutures are wrung in
this way. While twisting, the twister should be tugged
occasionally to determine whether any residual laxicity
remains. Otherwise, overuse of the twister may lead
to rupture of the tibial sutures. The twister can also
be used to set the transplant tension individually per
strand, while comparing it with the healthy opposite
side. If the single bundle technique is used, this
should be performed at approx. 30° knee flexion.
For this purpose, the twister is hooked into the Suture
Disk openings and the tension is increased gradually,
preferably in steps of clockwise half turns. After each
half turn, the tension is measured by pulling at the
twister handle until the suture disk is lifted off,
slightly, from the tibia. Experience so far shows that
the optimum tension is up to 40 units for female
patients and up to 70 units for males. As a precaution,
the sutures should be cut off only after the final
tension has been achieved.
The Suture Disk “L” (FO034T) with rotation lock reliably
prevents any back-rotation of the implant, thus helping to maintain the applied tension.
The Suture Disk centres the tendon in the tibial drill
channel. To prevent haemorrhages, the channel is nearly completely closed towards distal. The knots rest
in the depression of the disk so that the fixation is
supported at bone surface level and the distal implant
does not need to be removed.
With the distal fixation completed, the pull and flip
sutures are removed, the sartorius fascia is closed and
the wound is closed with an intracutaneous suture.
The separated sartorius fascia is sutured to the gracilis
tendon, which displaces the latter in the direction of
the former STT (sartorius reconstruction) and improves
inward rotation.
26
Operating technique
6 | Double Bundle Technique
If preparation of the semitendinosus tendon provides
a tendon graft that is both long enough for the
quadruple technique and also at least 7 mm thick,
the surgeon can switch from the single bundle to
the double bundle technique.
The multi-channel technique allows targeted reconstruction of the anteromedial and posterolateral
cruciate ligament bundles to produce anatomically
and kinematically correct conditions. Whereas the
anteromedial bundle stabilizes the higher degrees
of flexion, the posterolateral bundle becomes taut
at near extension and controls the screw-home
mechanism. Furthermore, the
diagonal course of the posterolateral bundle in the
frontal plane has an additional stabilizing effect on
the periphery, especially on the posterolateral corner
(rotational stabilization).
Using two femoral and tibial drill channels to receive
the transplant substantially increases the contact
surface between the tendon transplant and the bone
wall. This improves the blood supply to the tendon
transplant and also leads to increased formation of
“Sharpey’s fibres”, making the graft more resistant
to being torn from the bone.
anteromedial
posterolateral
The elements of the surgical procedure differing from
the single bundle technique are described below.
27
Operating technique
6 | Double Bundle Technique
Anteromedial bundle
In the double bundle technique also as much as
possible of the distal stump of the anterior cruciate
ligament should be retained for orientation purposes.
However, care must be taken in the tibial double
bundle technique to clean the area directly in front
of the posterior cruciate ligament to make the entry
point for the K-wire visible.
1. Tibial drill channel
The Tibial Aiming Device (FR500M) is inserted into the
joint. The target area is the transition from the ventral
third of the insertion to the middle third. The landmark
here is the position of the anterior horn of the lateral
meniscus. One should make sure that the tibial entry
point is only approx. 1 cm from the tibial tuberosity,
to leave space medially for placement of the tibial
posterolateral drill channel.
The K-wire entry is first drilled with the 4.5 mm drill
and then reamed to match the measured transplant
thickness.
2. Femoral drill channel
After the joint has been cleaned, the Femoral Aiming
Device is introduced through the anteromedial portal
and inserted behind the posterior fossa margin in the
11.30 position for the right knee or the 12.30 position
for the left knee. The knee is positioned in 110 – 120°
of flexion and the femoral K-wire is placed so as to
reach both cortices. Then, a pocket hole is formed
with the head reamer according to the femoral graft
diameter. The drill channel is completed using the
4.5 mm drill and the channel length is measured with
the Depth Probe.
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Posterolateral bundle
1. Tibial drill channel
In the subsequent step, the second Tibial Aiming
Device (FR507M for the left knee joint, FR508M for
the right knee joint) is inserted into the previously
drilled anteromedial tibial drill channel, so that the
tip of the aiming device is positioned behind the
dorsal circumference. At 90° knee flexion, the K-wire
should be visible inside the joint directly in front of
the ventral margin of the posterior cruciate ligament
and 3 mm medially from the lateral spina. Here too
drilling should be performed step by step according
to the diameter of the individual grafts.
2. Femoral drill channel
Because of the very diagonal course of the tibial
drill channel through the tibial head, the Aiming
Device for the posterolateral femoral drill channel
(FO011R) can be positioned easily in the targeted
position dorsal to the right lateral fossa margin, at
the 10.30 position for the right knee and the 1.30
position for the left knee. Care should be taken that
the knee is flexed to 100° (+/- 5°). Here also the
measured drill depth “B” should be drilled according
to the transplant diameter and completed with the
4.5. head reamer. To determine the knot length “K”,
the posterolateral femoral drill channel is also
measured with the Depth Probe (FO027R).
posteromedial drill
channel
anteromedial drill
channel
anteromedial drill
channel
posteromedial drill
channel
29
Operating technique
6 | Double Bundle Technique
Pulling the two cruciate ligament bundles
through
Both pullout pins are introduced through the anteromedial access and the suture loops are pulled with a
Micro-Forceps (OG335R) through the corresponding
tibial drill channels. To draw in the two transplants,
first the posterolateral pull-through pin is placed and
then an anteromedial pin. Using a similar sequence,
the transplants are pulled in, first the posterolateral
and then the anteromedial.
The Mini-Suture Disks (FO065T) are used to perform
the tibial fixation. The posterolateral bundle is knotted
at 10° close to the extensor and later tensioned. The
anteromedial bundle is knotted at approx. 45°. During
final tensioning particular care must be taken because
of the small size of suture used – 3 to 4 twists are
fully sufficient to build up tension. Increases in tension
must be very carefully tested to prevent
suture untwisting through the Suture Disk. To prevent
extensor deficits, it is preferable to pretension the
posterolateral bundle close to the extensor cautiously,
applying approx. 20 newtons of force. The anteromedial bundle is tensioned to 40 – 50 newtons at 45°
flexion in accordance with the joint play on the
opposite side. It is recommended to use the twister
(FO037R) routinely to determine if any residual
elasticity still remains in the suturing system.
30
Operating technique
7 | Postoperative Care
Long experience in working with experts in the fields
of sports medicine (Dr. J. Eichhorn, Sporthopaedicum, Straubing) and physiotherapy (e.g. at the Eden
Rehabilitation Centre, Donaustauf, Bavaria) has
proved the value of phased postoperative treatment. Multi-stage therapy respects the physiological
fundamentals (wound healing progress in the
affected structures), individual conditions, prerequisites for that patient, functional progress in the
activities of daily living (ADL), and the empirical
and pragmatic experiences of time- and cost-optimized rehabilitation. When clinical and functional
parameters indicate it, the patient can move on to
the next stage. Interindividual differences can be
optimally managed in this way and increased complications due to overly ambitious weight-bearing
can be avoided. The following general schedule is
suggested for the respective rehabilitation stages:
The following summarized specific targets may be
scheduled to match the particular therapy stages:
Overview of therapy targets, Stages 1–3
Stage Schedule
Therapy targets
l
Postoperative
weeks 1 and 2
ll
Postoperative
weeks 3 – 6
Stage 1
Stage 2
Stage 3
Acute or inflammation stage along with
the start of the proliferation stage –
weeks 1 and 2 on average
Proliferation stage along with the start
of the remodelling stage – weeks 3 to
6 on average
Remodelling stage – usually from week 7
lll
Postoperative
week 7
Pain alleviation/
reduction
Reduction of possible
swelling
Maintenance of mobility
in the femoral-patellar joint
Normalization of
mobility
Progressive increase in
weight-bearing to full
functionality
Restoration of coordination
capacity
Stabilization of the normal
pelvic-leg axis
Normalization of routine
motor functionality
Achievement of normal
muscle balance along the
entire pelvic-leg axis
31
Operating technique
7 | Postoperative Care
Stage 1
Manual lymph drainage
Training the patient in patellar self-mobilization towards distal
After surgery, the knee joint is first placed in a knee
immobilization splint with Velcro fasteners for a week.
Normally the splint is worn in full extension, and can
be replaced with a 20° splint only if additional sutures
are placed on the posterior horn of the lateral meniscus
or by activation of the medial collateral ligament, and
in these cases, the maximum wear period is 2 weeks.
It has been shown that patients can receive their first
lymph drainage right in the recovery room – the lymph
vessels were compressed by the haemostatic bandage
but can be quickly reopened by massaging the lymph
circulation. This promotes the metabolism in the leg.
On the first postoperative day, the drains are removed
and the patient is immediately shown how to perform
patellar mobilization exercises. Otherwise there is a
risk that the small recesses near the patella may
develop adhesions and the patella may become hypomobile, resulting in ventral knee pain. In addition to
the immobilization splint, a CryoCuff (Aircast) for
example can be used, which allows cold water to be
pumped intermittently or continuously around the
knee. Ice packs should be completely avoided in the
postoperative period because the chilling effect is
excessive.
On the first postoperative day also, the patient is
treated with electrostimulation of the vastus medialis
muscle since experience shows that physiotherapy
reaches the vastus medialis muscle only very poorly
in this first stage of therapy.
Particular attention should be given to postoperative
pain therapy since otherwise very severe pain will
cause the operated limb to disconnect from the cerebellum, and this can only with difficulty be restored
to a movement pattern through intensive physiotherapy.
32
On postoperative day 3, a dynamic splint with
unlimited range may be used. This will allow the
patient to direct movement, actively for the most
part, through the non-operated leg to the splint.
Irradiation also helps promote innervation in the
operated leg through the overflow phenomenon.
Heavy emphasis should be placed on proprioceptive
capabilities in Stage 1. The Hanke E-technique is
particularly effective; the immediate postoperative
recall of walking and turning patterns can preserve
neuromuscular connections. Elyth ointment bandages may be used to reduce oedema and normalize
the postoperative tissue pH.
Preservation of neuromuscular connections in movement patterns using
the Hanke E-technique
It is important not to engage in any strenuous
knee-flexion activities during the first two to three
weeks. Furthermore, active stretching of the flexors
should be avoided otherwise the small remaining
attachments of the semitendinosus at the periphery
may tear, resulting in the muscle belly snapping
upwards which hinders the tendon reattachment. In
this first stage of therapy, the patient should start
to engage in half weight-bearing with the aid of
two crutches, concentrating at this point on the
achievement of a very smooth gait pattern during
gait training. Since this stage of therapy is performed
mostly at rest, it must be accompanied by a regimen
of thromboembolic prophylaxis with low molecular
weight heparin and adequate pain medication.
In the second week, lymph drainage is continued.
Furthermore, ointment bandages should be applied,
manual physiotherapy exercises should be started
to improve joint mobility by gentle traction, and
attention should be given especially to mobilizing
the capsule, patella, and menisci.
33
Operating technique
7 | Postoperative Care
By the end of the second week, 0/10/90° mobility
should be achieved. With the aid of a ski boot, for
example, to assist gravity, and by engaging in selfmobilization and self-traction exercises, patients can
comfortably improve their mobility (flexion) also at
home and ward off the onset of pain and swelling.
There should be a gradual or at least a very noticeable
decrease in swelling. If these goals are reached, the
patient is ready to move to Stage 2.
Auto-mobilization of the kneejoint in extension by using a ski shoe
Stage 1 complications
In rare cases, a haematoma may form at the tendon
donor site, which can then manifest on the third or
fourth postoperative day because of sluggish circulation from the short-acting anaesthetic.
Many patients complain of shooting pains and a sensation of tightness in the operated area of the leg when
they stand up. This is due to the still impaired functioning of the lymph and vein pumps – the return circulation of the blood components back to the heart is still
inadequate.
Some patients also report reddening and tension pain
around the tibial tendon anterior compartment, but
this regresses significantly after 8–10 days.
Patients should be clearly instructed that in the event
of fever, throbbing pain or reddening at the knee joint,
they must immediately inform their surgeon since
early detection and immediate initiation of appropriate
treatment are a critical part of joint infection
management.
At this initial stage, the knee joint should only be
punctured in the event of tension pain at rest.
34
Stage 2
The success of the operation is supported postoperatively with a FourcePoint brace, which helps soften
the stress of daily living for six weeks. When physiotherapy exercises are performed, it has to be removed.
The goal of Stage 2, which lasts until the sixth week
after surgery, is the achievement of full mobility
with no effusions or pain in the joint. A follow-up
examination is usually performed after four weeks.
If persistent deficits in rehabilitation are detected at
that point, these should be immediately managed
with targeted physiotherapy programmes. In more
severe cases, about two weeks of inpatient rehabilitation may be necessary. The combination there of all
physiotherapy and physical resources nearly always
resolves the problem and in most cases obviates a
recourse to revision operations to improve mobility.
Promotion of proprioceptively guided knee joint stability with single leg
half-knee flexions on a Posturomed training platform
The training exercises in Stage 2 are characterised
by targeted co-contractions with tensioning of the
extensors and flexors. The Posturomed Proprio-Swing
has proved very beneficial in this regard: it allows
the patient to train the neuromuscular connection
by gentle flexion (co-contraction) on a platform
with built-in instability. This is very safe since the
joint is not confronted with angle acceleration when
using this device. At this stage also, the patient can
begin to slowly decrease the use of crutches.
35
Operating technique
7 | Postoperative Care
Intensive medical exercise therapy is still not encouraged at this stage; graft stability still depends on the
stability of the primary fixation, and Sharpey’s fibres
– the source of secondary fixation – develop only
slowly over this second stage and until the end of the
sixth week. Cautious medical exercise therapy can be
started therefore towards the end of Stage 2 (weeks
5-6). Active exercises can also be gradually intensified,
especially for the vastus medialis muscle, to eliminate
further need for electrostimulation.
Initiation, enhancement and stabilization of gait patterns on the minitrampoline to promote co-activation
The illustration on the left shows an option which can
also be performed at home – appropriate facilitation of
the vastus medialis muscle by generation of isometric
stress with a Theraband while seated. In Stage 2, many
patients can return to work if it does not require
strenuous bodily effort.
Knee extension exercise with abduction stress using the Theraband to
promote facilitation of the vastus medialis muscle
36
If an aquatic exercise pool is available, intensive
exercises can readily be performed because of the
positive hydrostatic pressure of the water and
reduction of body weight. The use of this resource
in particular often produces surprisingly fast and
excellent results. The most common types of exercise equipment for Stage 2 include the exercise
bicycle at the start of the stage and the ellipsoid
trainer (cross-walker) at the end.
Ellipsoid trainer
37
Operating technique
7 | Postoperative Care
Stage 2 complications
In this stage also one should be on the watch for tardive infection manifested by increased swelling, pulsating pain, or an excessively warm joint. Furthermore,
should overloading occur – especially in flexor training – repeated tearing in the area of the ischiocrural
musculature with a loss of function in the semitendinosus muscle may result; the event, however, does
not have any particular functional implications.
Should significant effusion formation still occur
towards the end of the 6–8 week period, a single injection of intra-articular corticosteroid (e.g. Lipotalon)
can be performed, which in most cases will clear up
the hyperreactive tendency. If it does not do so, the
patient should undergo a nuclear magnetic resonance
examination. Scar tissue or the development of a
cyclops syndrome is frequently responsible for the
hyperreactive problem.
If such is the case, appropriate therapeutic measures
should be started, including an investigative arthroscopic intervention, if necessary.
Follow-up arthroscopic intervention should also be
considered if by the end of Stage 2 the extensor is
more than 10° impaired or there is a flexor deficit of
more than 20°. Such complications are more easily
managed especially at this early stage.
38
Stage 3
At this point most patients perform self-exercises
under the guidance of a physiotherapist. The first
walks can be on level ground. Exercise bicycle and
cross-walker exercises are intensified. Professional
athletes may now start sport-specific exercises
which are targeted to achieve the muscular quality
required for the specific sport. Emphasis is placed
on improvement in complex coordination ability,
with the use of continuously more challenging
exercises. There is increasing use also of some of
the open kinetic chain exercises for weight-bearing
since these qualities are necessary in most types of
sports. Special attention is given in this stage also
to improving the basic endurance performance of
the athlete through targeted exercises.
Controlled knee half-flexion with varus stress to activate the medial
stabilisers of the knee joint
After five months, an “Ortho check” should be
performed, during which parameters such as endurance, resilience, responsiveness, coordinative capacity (proprioception), etc. are tested. Any deficits
discovered should be targeted for further treatment
so that professional athletic ability is recaptured by
the fifth to seventh month after surgery. Fewer
exercise components are generally prescribed for
recreational athletes and in their case the recapture
of athletic ability may take up to 8 months.
Ortho Check© Functional Analysis
Strength
Endurance
Resilience
Proprioception
Clinical status
Biomechanics
Patient
pathological deficit
ADL
able to do sports
Diagram of results of the Ortho Check
39
Implants
40
FO030T Suture Plate Sterile,
titanium alloy
4 x 12 mm
POSITION Endless Loop
FO070T, 20 mm
FO071T, 25 mm
FO072T, 30 mm
FO073T, 35 mm
FO074T, 40 mm
FO075T, 45 mm
FO076T, 50 mm
FO035T Suture Disk “S” Sterile,
titanium
Ø 14 mm
FO065T Mini Suture Disk Sterile,
titanium
Ø 11 mm
FO034T Suture Disk “L”
with rotation lock
Titanium
Ø 14 mm
FO039 Implantation set for STT, sterile comprising:
1 x Suture Plate FO030T
1 x Suture Disk “L” FO034T
4 x Premicron®, USP2, HRT 37, 75 cm
1 x Dagrofil®, USP6, 150 cm
1 x Dagrofil®, USP2, 150 cm
1 x Surgical Loop, 4 mm, 75 cm
FO040 Implantation set for STT, sterile
comprising:
1 x Suture Plate FO030T
1 x Suture Disk “S” FO035T
4 x Premicron®, USP2, HRT 37, 75 cm
1 x Dagrofil®, USP6, 150 cm
1 x Dagrofil®, USP2, 150 cm
1 x Surgical Loop, 4 mm, 75 cm
FO042 Implant set for DB-ACL fixation
2 x FO030T Position Suture Plate
2 x FO065T Position Mini Suture Disk
1 x Premicron® USP2 HRT 37 (M) DDP, green, 4 x 75 cm,
REF 0026717
1 x Dagrofil® USP2, white, 1 x 150 mm, REF 0372102
2 x Dagrofil® USP6, green, 1 x 150 mm, REF 0342149
1 x Surgical Loop 4 mm, green, 1 x 75 mm,
REF 1094912
FO043 Implant set for tibial ACL fixation, lock
1 x FO034T Position Suture Disk “L”
1 x Premicron® USP2 HRT 37 (M) DDP, green, 4 x 75 cm,
REF 0026717
41
Implants
42
FO044 Implant set for tibial ACL fixation, standard
1 x FO035T Position Suture Disk “S”
1 x Premicron® USP2 HRT 37 (M) DDP, green, 4 x 75 cm,
REF 0026717
FO045 Implant set for tibial DB-ACL fixation
2 x FO065T Position Mini Suture Disk
1 x Premicron® USP2 HRT 37 (M) DDP, green, 4 x 75 cm,
REF 0026717
FO046 Implant set for femoral ACL fixation
1 x FO030T Position Suture Plate
1 x Dagrofil® USP2, white, 1 x 150 mm, REF 0372102
2 x Dagrofil® USP6, green, 1 x 150 mm, REF 0342149
1 x Surgical Loop 4 mm, green, 1 x 75 mm, REF 1094912
Basic instrument set
Femoral aiming devices
FO012R Femoral aiming device
3 mm offset
FO013R Femoral aiming device
4 mm offset
off-set
FO010R Femoral aiming device (not illustrated)
5 mm offset
FO006R Femoral aiming device (not illustrated)
6 mm offset
FO007R Femoral aiming device (not illustrated)
7 mm offset
FO011R Femoral aiming device
for posterolateral drill channel in femoral double
bundle technique
43
Basic instrument set
Tibial aiming devices
44
FR500M Transtibial aiming device
FR507M Tibial aiming device (not illustrated)
for posterolateral drill channel in double bundle
technique, left
FR508M Tibial aiming device
for posterolateral drill channel in double bundle
technique, right
Instruments
Tendon strippers
Effective length: 340 mm,
graduated shank
FO023R
Inner diameter 6 mm
FO024R
Inner diameter 7 mm
FO032R Rasp (not illustrated)
FO027R Depth probe
Effective length 300 mm
FO028R Knot pusher
FO014R Notch gauge
FO037R Twister
for FO034T and FO035T
FO067R Mini-Twister (not illustrated)
for FO065T
45
Basic Instrument Set
Suture Board
FO029 Suture Board
– Incl. 2 tissue clamps (FO029850), implant holder,
pretensioning attachments, and
baby mosquito clamp (BH104)
– Modular setup for individual OR procedures
– Reliable recordings and measurement scales for
tendon preparation
– Implant fixation for transplant pre-tensioning
FO031 Suture Board
– Addition to FO029 when using the double bundle
technique
46
Drills
Head reamer
2-wing, cannulated (2.6 mm)
hexagonal shaft, length: 180 mm
FO081R, Ø 5 mm
FO088R, Ø 8.5 mm
FO082R, Ø 5.5 mm
FO089R, Ø 9 mm
FO083R, Ø 6 mm
FO090R, Ø 9.5 mm
FO084R, Ø 6.5 mm
FO091R, Ø 10 mm
FO085R, Ø 7 mm
FO092R, Ø 10.5 mm
FO086R, Ø 7.5 mm
FO093R, Ø 11 mm
FO087R, Ø 8 mm
hexagonal shaft, cannulated
length: 205 mm
FO079R, Ø 4.5 mm
hexagonal shaft, not cannulated
length: 205 mm
FO078R, Ø 4.5 mm
Drill, tibial
cannulated (2.6 mm)
hexagonal shaft, length: 160 mm
FR541R, Ø 5 mm
FR548R, Ø 8.5 mm
FR542R, Ø 5.5 mm
FR549R, Ø 9 mm
FR543R, Ø 6 mm
FR550R, Ø 9.5 mm
FR544R, Ø 6.5 mm
FR551R, Ø 10 mm
FR545R, Ø 7 mm
FR552R, Ø 10.5 mm
FR546R, Ø 7.5 mm
FR553R, Ø 11 mm
FR547R, Ø 8 mm
Tissue protection sleeves (not illustrated)
e.g. for determining transplant thickness
Inner diam./Ø
FR705S, Ø 5.5 mm
FR576S, Ø 6 mm
FR706S, Ø 6.5 mm
FR577S, Ø 7 mm
FR707S, Ø 7.5 mm
FR578S, Ø 8 mm
FR708S, Ø 8.5 mm
FR579S, Ø 9 mm
FR709S, Ø 9.5 mm
FR580S, Ø 10 mm
FR710S, Ø 10.5 mm
FR581S, Ø 11 mm
47
Instruments
Dilators
Eccentric dilators
The key to success within the cruciate ligament
surgery is the essential precision of the drill tunnel
position.
Dr. Heinz-Jürgen Eichhorn, MD
sporthopaedicum straubing, Straubing, Germany
The aiming devices available on the market often do
not grant the essential precision, so that suboptimal
drill tunnel positions are accepted. In the context
of permanent improvement and extension of the
POSITION instruments, eccentric dilators have been
developed, which allow a correction of the drill tunnel
position.
After over-drilling the k-wire with the 4.5 mm drill,
the precision of the tunnel position has to be checked
through dislutching the arthroscope in the anteromedial porta and use of the palpation hook. Pretty
often also an experienced surgeon must state that the
drill tunnel position is not optimal.
Offset
By using the eccentric dilators in different diameters it
is possible to extend the drill tunnel through the offset
of the eccentric dilators in the favoured optimized
direction. In this way result-worsening compromises of
the drill tunnel situation can be corrected and therefore avoided.
Heinz-Jürgen Eichhorn
final drill tunnel
Ø 4.5 mm
drill tunnel
Dilators, eccentric
48
FR817R, Ø 5.5 mm OFFSET 0.75 mm
FR818R, Ø 6.0 mm OFFSET 1.0 mm
FR819R, Ø 6.5 mm OFFSET 1.25 mm
FR820R, Ø 7.0 mm OFFSET 1.5 mm
Dilators
FR750 Drill channel dilator set
comprising:
FR751R Storage tray
FR752R Handle with extraction hammer
FR775R – FR781R Dilators, sharp
FR785R – FR790R Dilators, sharp
(round dilators must be ordered separately)
FR793R – FR795R Tibial guide pins
FR753R Femoral guide pin
FR751R Storage tray for dilators (not illustrated)
FR752R Handle with extraction hammer
Dilators, sharp
FR775R, Ø 5 mm
FR776R, Ø 6 mm
FR777R, Ø 7 mm
FR778R, Ø 8 mm
FR779R, Ø 9 mm
FR780R, Ø 10 mm
FR781R, Ø 11 mm
Dilators, blunt
FR755R, Ø 5 mm
FR756R, Ø 6 mm
FR757R, Ø 7 mm
FR758R, Ø 8 mm
FR759R, Ø 9 mm
FR760R, Ø 10 mm
FR761R, Ø 11 mm
FR785R, Ø 5.5 mm
FR786R, Ø 6.5 mm
FR787R, Ø 7.5 mm
FR788R, Ø 8.5 mm
FR789R, Ø 9.5 mm
FR790R, Ø 10.5 mm
FR765R, Ø 5.5 mm
FR766R, Ø 6.5 mm
FR767R, Ø 7.5 mm
FR768R, Ø 8.5 mm
FR769R, Ø 9.5 mm
FR770R, Ø 10.5 mm
Tibial guide pins, movable head
FR793R, Ø 4.5 mm
FR794R, Ø 6 mm
FR795R, Ø 8 mm
Femoral guide pin, fixed head
FR753R, Ø 4.5 mm
49
Instruments
FO038R Measuring block
For measuring the transplant thickness
K-wires
FO025R
Drill and pullout pin with drill helix and eye,
Total length: 380 mm, shaft: Ø 2.4 mm
Tip: Ø 2.7 mm
FO036R
Drill and pullout pin with eye
Total length: 380 mm , Ø 2.5 mm
LX045S
K-wire
Total length: 310 mm, Ø 2.5 mm
FO002R ACL Basic Instrument Storage Case
– POSITION open basket with storage for Suture
Board FO029 ensuring reliable, gentle and rapid
storage and preparation of instruments
– comprising:
JF222R Open Basket
FO002/200 silicone storage insert for POSITION
FO003R ACL Basic Instrument Storage Case
– POSITION open basket with storage for implants
and instruments
– comprising:
JF222R Open Basket
FO003/200 silicone storage insert for POSITION
50
Additional instruments
OG335R Micro forceps
Straight, 5 x 1 mm
BM016R Durogrip Crile Wood needle holder
145 mm
51
Storage
Recommended Containers
JK440 container
– 1 tray
– Outer dimensions: 592 x 274 x 90 mm
e.g. for storing FR751R (dilators)
JK442 container (no illustration)
– 2 trays
– Outer dimensions: 592 x 274 x 135 mm
e.g. for storing FO002R and FO003R
(ACL Basic Instruments)
JP001 PrimeLine Container Cover, red
– 1 cover, available in several colours
– For JK440 or JK442, red
JG785B Label, red
– Accepts up to 13 characters
– 4 labels per container recommended
JF436R Optiktray
– Optiktray for reliable storage during transport,
cleaning and sterilization of arthroscopes,
e.g. PE545A
– Shaft diameters from 2.7 mm
– Shaft lengths from 140 mm to 200 mm
– Dimensions: 273 x 84 x 41 mm
52
Notes
53
The main product trademark ‘Aesculap’ is a
registered trademark of Aesculap AG. ‘Dagrofil’
is a registered trademark of B. Braun Melsungen
AG. ‘PremiCron’ is a registered trademark of
B. Braun Surgical GmbH.
Aesculap AG | Am Aesculap-Platz | 78532 Tuttlingen | Germany
Phone +49 7461 95-0 | Fax +49 7461 95-26 00 | www.aesculap.com
Subject to technical changes. All rights reserved.
This brochure may only be used for the exclusive
purpose of obtaining information about our
products. Reproduction in any form partial or
otherwise is not permitted.
Aesculap – a B. Braun company
Brochure No. O13602
0912/1/5