Aesculap® POSITION ACL The anterior cruciate ligament reconstruction system Operating technique

Aesculap Orthopaedics

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Table of contents

POSITION ACL Anterior cruciate ligament reconstruction system

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Operating technique 1 | Transplant selection

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2 | Transplant harvesting

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3 | Drill channels

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4 | Transplant preparation

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5 | Transplant insertion and fixation

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6 | Double Bundle Technique

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7 | Postoperative Care

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Implants

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Basic instrument set Femoral aiming devices

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Tibial aiming devices

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Instruments

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Basic Instrument Set Suture Board

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Drills

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Instruments Dilators

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Instruments

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Storage Additional instruments

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Recommended Containers

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POSITION ACL – anterior cruciate ligament reconstruction system

FR507M

FO010R

FO029

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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 are perfectly matched to one another – and are simply presented in a single sterile pack – for optimum 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

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Disadvantages 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 10 m

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.

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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.

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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.

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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

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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.

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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:

Stage 1

Acute or inflammation stage along with the start of the proliferation stage – weeks 1 and 2 on average

Stage 2

Proliferation stage along with the start of the remodelling stage – weeks 3 to 6 on average

Stage 3

Remodelling stage – usually from week 7

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

Pain alleviation / reduction Reduction of possible swelling Maintenance of mobility in the femoral-patellar joint

ll

Postoperative weeks 3 – 6

Normalization of mobility Progressive increase in weight-bearing to full functionality Restoration of coordination capacity Stabilization of the normal pelvic-leg axis

lll

Postoperative week 7

Normalization of routine motor functionality Achievement of normal muscle balance along the entire pelvic-leg axis

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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.

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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.

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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.

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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.

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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

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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

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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.

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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

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Implants

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

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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

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Implants

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

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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

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Basic instrument set Tibial aiming devices 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

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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

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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

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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

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Instruments 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

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

Dilatatoren, stumpf 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

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 FR573R, Ø 4.5 mm

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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

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Storage Additional instruments OG335R Micro forceps Straight, 5 x 1 mm

BM016R Durogrip Crile Wood needle holder 145 mm

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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

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The main product mark ’Aesculap’ is a registered mark of Aesculap AG.

Aesculap AG | Am Aesculap-Platz | 78532 Tuttlingen | Germany Phone +49 (0) 74 61 95-0 | Fax +49 (0) 74 61 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

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