Abstract
The TightRope RT (Arthrex, Naples, FL) is a suspensory device for anterior cruciate ligament reconstruction. However, there is a potential risk of the button being pulled too far off the lateral femoral cortex into the soft tissue because the adjustable loop is long. The purpose of this article is to present an easy and safe technique for self-flip. As to the preparation of the graft, we draw the first line in the loop of the TightRope RT at the same length as the femoral tunnel, and we draw the second line 7 mm longer than the length of the femoral tunnel as a self-flip line. Concerning passing of the graft, the side sutures are pulled from the lateral side. We stop pulling the sutures just at the self-flip line by holding the graft at the tibial end. The side suture is inclined to the medial side with strong pulling of the suture at full extension of the knee. Then the surgeon pulls the tibial end of the graft to feel a secure positioning of the button on the lateral femoral cortex. Although it has limitations, the present technique is easy and certainly helps surgeons achieve appropriate positioning of the button.
The TightRope RT (Arthrex, Naples, FL) is a fixation device for anterior cruciate ligament (ACL) reconstruction. It has an adjustable loop that fits all sizes of tunnels, and it is not necessary for orthopaedic surgeons to create an extra socket (6 to 7 mm) to facilitate button flipping. Therefore, relatively short femoral tunnels will be beneficial for anatomic soft-tissue ACL reconstruction. However, there is no side suture in the TightRope RT button for flipping. In addition, there is a potential risk that the button will be pulled too far off the lateral femoral cortex into the soft tissue and lead to inappropriate positioning of the button on the vastus lateralis muscle or fascia, because the loop of the TightRope RT is long. From 2014, a side suture was added to the TightRope RT and it resembles the EndoButton (Smith & Nephew Endoscopy, Andover, MA). However, flipping the TightRope RT is still difficult because the hole of the flipping suture is close to the central area. So far, various techniques have been reported to seat the TightRope RT button appropriately on the lateral cortex of the femur.1, 2 However, the reported techniques are relatively difficult.
We describe a safe and easy technique of self-flipping using the TightRope RT button to achieve the appropriate position on the lateral cortex of the femur (Video 1).
Technique
The patient is placed supine with a standard leg holder (Mizuho, Tokyo, Japan) allowing the full range of motion under general anesthesia. First, the semitendinosus graft is harvested using the tendon stripper (Arthrex) and looped with the TightRope RT, and the artificial ligament (Leeds-Keio; Xiros, Leeds, England) is used for the hybrid technique. For the hybrid technique, free limbs of the graft are whipstitched with No. 1 nonabsorbable sutures (Surgilon; Covidien, Mansfield, MA). Each stitch must pass through each strand of graft collagen, and the suture limbs are wrapped twice around the collagen bundles, creating a self-reinforcing suture noose. Then, the artificial ligament is looped, followed by whipstitches using No. 1 nonabsorbable sutures. As preparation, the appropriate diameter of the tibial tunnel is created using the ACL tibial guide (Arthrex), and the appropriate diameter of the femoral tunnel is also created using the inside-out or outside-in technique using the ACL femoral guide (Arthrex) under the arthroscopy. A 15-mm femoral socket is then created with a drill (Arthrex) adjusted to the diameter of the graft. As to the preparation of the graft, we draw a first line in the loop of the TightRope RT at the same length as the femoral tunnel, and then draw a second line 7 mm longer than the length of the femoral tunnel as a self-flip line. Moreover, the third line is drawn on the graft at 15 mm from its end that is the same length as the femoral socket (Fig 1).
Fig 1.
Preparation of the graft. The artificial ligament (Leeds-Keio; Xiros) is used for the hybrid technique. For the hybrid technique, free limbs of the graft are whipstitched with No. 1 nonabsorbable sutures (Surgilon; Covidien). Each stitch must pass through each strand of graft collagen, and the suture limbs are wrapped twice around the collagen bundles, creating a self-reinforcing suture noose. Then, the artificial ligament is looped, followed by whipstitches using No. 1 nonabsorbable sutures. Thereafter, we draw the first line in the loop of the TightRope RT (Arthrex) at the same length as the femoral tunnel (black arrow), and draw the second line 7 mm longer than the length of the femoral tunnel as a self-flip line (white arrow). Moreover, the third line is drawn on the graft at the same length as the femoral socket (15 mm) (pink arrow).
A braided No. 5 suture (Ethibond; Ethicon, Somerville, NJ) is passed from the tibial tunnel to the femoral socket and brought out of the skin laterally. The TightRope RT passing sutures are passed through the tibial tunnel and then through the femoral socket and brought out laterally using the suture. The side sutures (blue sutures) are then pulled from the lateral side, with the TightRope RT button being pulled into the femoral socket under direct arthroscopic vision. We confirm the drawn lines in the loop of the TightRope RT through the anterolateral portal. We then stop pulling the TightRope RT button just at the second line (self-flip line) (Fig 2).
Fig 2.
The side sutures (blue sutures) are pulled from the lateral side, with the TightRope RT (Arthrex) button being pulled into the femoral socket under direct arthroscopic vision. We confirm the first and second lines in the loop of the TightRope RT through the anterolateral portal. We then stop pulling the TightRope RT button just at the second line (white arrow, self-flip line).
We should hold the graft at the tibial end on the anterior side not to pull too far. Then, the arthroscope should be removed, and the knee position is changed from 90° flexion to full extension. It is necessary to pull the side suture strongly, with the surgeon holding the graft at the tibial end (Fig 3). The side suture (blue suture) is inclined to the medial side with strong pulling of the suture (Fig 4). Then the surgeon pulls the tibial end of the graft until he or she feels a secure positioning of the TightRope RT on the lateral side of the femoral cortex. The knee position is changed from full extension to 90° flexion. We should insert the arthroscope again and confirm the first line is just at the exit of the femoral tunnel through the anterolateral portal (Fig 5). Thereafter, final tensioning of the graft is made by pulling the white loop until the third line on the graft is aligned to the exit of the femoral tunnel. Countertraction on the tibial end of the graft is applied during graft final tensioning. Finally, double stapling is done for tibial fixation at 20° of knee flexion.
Fig 3.
We hold the graft at the tibial end on the anterior side so as not to pull too far. Thereafter, the arthroscope should be removed, and we change the knee position from 90° flexion to full extension. It is necessary to pull the side suture strongly with the surgeon holding the graft at the tibial end.
Fig 4.
The side suture (blue suture) is inclined to the medial side with strong pulling of the suture. Then, the surgeon pulls the tibial end of the graft until he or she feels a secure positioning of the TightRope RT (Arthrex) on the lateral side of the femoral cortex. Thereafter, the knee position is changed from full extension to 90° flexion.
Fig 5.
We insert the arthroscope again in 90° of knee flexion. We can confirm the first line (black arrow) as the same length of the femoral tunnel through the anterolateral portal and the second line (white arrow, self-flip line). Thereafter, final tensioning of the graft is made by pulling the white loop until the third line on the graft aligned to the exit of the femoral tunnel. Countertraction on the tibial end of the graft is applied during graft final tensioning.
A postoperative radiograph is obtained for each patient to confirm the appropriate positioning of the button (Fig 6). In the recent 100 cases, 98% of the buttons were seated correctly on the lateral cortex of the femur.
Fig 6.
A postoperative radiograph is obtained for each patient to confirm the appropriate positioning of the button.
Discussion
According to previous studies, malpositioning of the EndoButton may lead to either soft-tissue irritation or migration of the button.3, 4, 5, 6 In addition, a previous study indicated that a rate of soft-tissue interposition between the EndoButton and the lateral cortex of the femur would be up to 25.2% on postoperative radiographs obtained after ACL reconstruction.4 A positive correlation between this complication and a higher rate of button migration was also seen. This technical error can result in a worse clinical outcome. The TightRope RT is a cortical suspensory fixation device for soft-tissue ACL reconstruction, and it has many advantages compared with other fixation devices. For example, according to Lubowitz,7 all-inside ACL reconstruction is possible using the device, because we can manually increase the femoral adjustable loop length before insertion of the graft. Furthermore, the ability to retension the graft after cycling the knee through a range of motion is important. Retensioning enables removal of creep from the graft, providing a more secure final construct.8 However, it is relatively difficult to achieve the appropriate position on the lateral cortex of the femur. According to recent papers, direct visualization of the button is recommended.1, 2 In our experience, expert skill is required for the reported techniques. In the present technique, 10 novice surgeons performed the procedure for the self-flip, and no complications were observed.
There are some key points in this technique (Table 1). First, we should draw the first and second lines in the loop (not the graft) of the TightRope RT to reduce the friction and to make the graft passage easier. Second, knee extension is required to reduce the tension of the quadriceps. In our experience, it is relatively difficult for the surgeon to feel the button caught at 90° of knee flexion. Third, we should not pull strongly without holding the graft at the tibial end. Otherwise, it is possible that the surgeon will pull the button too far on the lateral cortex of the femur and soft-tissue interposition of the button can occur, which may worsen clinical outcomes. Lastly, the self-flip should be done by the surgeon (not the assistant) to confirm the feeling that the button is caught on the lateral cortex of the femur. The surgeon should pull the tibial end of the graft until he or she feels a secure positioning of the TightRope RT on the lateral side of the femoral cortex. The advantages of the self-flip are as follows: easy preparation of the graft, easy confirmation of the drawn line as the same length of the femoral tunnel, safe procedure for the patient, easy procedure for novice surgeons, and it does not take much time (Table 2).
Table 1.
Tips and Tricks of Procedure From Our Experience
| Indications |
| All anterior cruciate ligament (ACL) reconstruction surgery using TightRope RT (Arthrex) |
| Surgical steps |
| Preparation |
| Appropriate diameter of the femoral tunnel is created using the inside-out or outside-in technique |
| Appropriate diameter of the tibial tunnel is created using the ACL guide |
| Draw the first line in the TightRope RT at the same length as the femoral tunnel |
| Draw the second line at 7 mm longer than the length of the femoral tunnel as a self-flip line |
| Mark the third line on the graft at 15 mm from its end that is the same length as the femoral socket |
| Arthroscopic visualization of the self-flip line |
| Pull the side suture (blue suture) |
| Confirm the drawn lines in the loop of the TightRope RT through the anterolateral portal |
| Stop pulling the TightRope RT just at the second line (self-flip line) |
| Self-flip technique |
| Hold the graft at the tibial end on the anterior side not to pull too far |
| Remove the arthroscope |
| Change the knee position from 90° flexion to full extension |
| Pull the side suture strongly, with the surgeon holding the graft at the tibial end |
| Incline the side suture to the medial side with strong pulling of the suture |
| Pull the tibial end of the graft until feeling a secure positioning of the button on the lateral cortex |
| Arthroscopic visualization of the line as the same length of the femoral tunnel |
| Confirm the first line as the same length of the femoral tunnel |
| Use countertraction on the tibial end of the graft during graft final tensioning |
Table 2.
Key Points, Advantages, and Limitations of This Procedure From Our Experience
| Key points |
| Draw the first and second lines in the loop (not the graft) of the TightRope RT (Arthrex) |
| Knee extension is required to reduce the tension of the quadriceps |
| Do not pull strongly without holding the graft at the tibial end |
| Self-flip should be done by the surgeon (not the assistant) |
| Advantages |
| Easy preparation of the graft |
| Easy confirmation of the drawn line as the same length of the femoral tunnel |
| Safe procedure for the patient |
| Easy procedure for novice surgeons |
| It does not take much time |
| Limitations |
| Position of the TightRope RT button cannot be seen directly |
| Perform the procedure once again if the TightRope RT button is not flipped |
Although it has many advantages, several limitations of the present technique should be described. First, the position of the Tightrope RT button cannot be seen directly using arthroscopy, unlike the previously reported techniques. We must ensure the position of the button using the 2 lines drawn on the loop. Second, the procedure should be repeated if the button is not flipped and the surgeon cannot feel the secure positioning of the TightRope RT on the lateral side of the femoral cortex. Nevertheless, the technique we have described can facilitate the use of the TightRope RT button.
Acknowledgment
The authors thank Hiroaki Suzuki for editorial assistance in the preparation of the article.
Footnotes
The authors report that they have no conflicts of interest in the authorship and publication of this article.
Supplementary Data
Self-flip technique of the TightRope RT button (Arthrex) for soft-tissue anterior cruciate ligament reconstruction is shown in a right knee (case 1) and in a left knee (case 2). The patient is placed in the supine position on the operating table, and the anterolateral portal is the viewing portal. After preparation of the graft and the creation of the bone tunnels, the side sutures of the button are pulled from the lateral side to pass the graft. Surgeons stop pulling the sutures just at the appropriate line by holding the graft at the tibial end. The side suture is inclined to the medial side with strong pulling of the suture at full extension of the knee. Then the tibial end of the graft is pulled to feel a secure positioning of the button on the lateral femoral cortex.
References
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Associated Data
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Supplementary Materials
Self-flip technique of the TightRope RT button (Arthrex) for soft-tissue anterior cruciate ligament reconstruction is shown in a right knee (case 1) and in a left knee (case 2). The patient is placed in the supine position on the operating table, and the anterolateral portal is the viewing portal. After preparation of the graft and the creation of the bone tunnels, the side sutures of the button are pulled from the lateral side to pass the graft. Surgeons stop pulling the sutures just at the appropriate line by holding the graft at the tibial end. The side suture is inclined to the medial side with strong pulling of the suture at full extension of the knee. Then the tibial end of the graft is pulled to feel a secure positioning of the button on the lateral femoral cortex.