Good morning, I'm Travis Decker coming from the Air Force Academy. I'll be presenting an all-inside ACL reconstruction technique with quadriceps autographed. I'll be presenting a variety of tips and tricks and alternative methods where you can easily adapt your current surgical technique to an all-inside technique if this is something that you desire to do and want to attempt in helping your patients. But I'd first like to start with thanking Matt McNutt and Kim Santinello putting this together through the education committee and platform in order to help patients ultimately but also aid us as surgeons to make us more efficient and better technicians as we try and attack these different types of surgeries in a better and more efficient way. And so I'll begin by discussing just my disclosures, I have nothing financially to disclose, however I do have my professional disclosures in that the tips and techniques have all been learned from a variety of sources, specifically those of where I trained with my mentors at Duke and Stedman teaching me a variety of tips and tricks to safely and effectively be able to have a reproducible surgical technique that will help and aid the patients. So specifically when it comes to the all-inside technique I think optimization of the visualization is absolutely key. I'll be using that AM portal so once again when you hyperflex that knee being able to identify everything and see exactly how far you're reaming these tunnels is essential to be able to make sure that you're going to be able to get enough graft in as well as be able to dunk the graft through this all-inside technique. This is a matter of mathematics, Dr. Pat Joyner out of the Andrews Institute when he was in fellowship who's really involved with the education forum and platform as well, he was able to predict graft length just based off of Blumensad's measurements and so I do this before every case where I look at these lateral radiographs and within two millimeters you're able to predict what that graft, intra-articular graft length is going to be. So this way you can plan for how long your tunnels are going to be and just so you know with tunnel length at the end how much graft to pass into each tunnel. This also requires you to clear that soft tissue, this is part of the visualization. Then lastly depending on which graft you have you want to be very cognizant of how you're tensioning this graft at the end of the case. I use a quadriceps graft which has been known to have some limitations of extension at the end of the case and so I make sure that I'm not going to over constrain the joint by tensioning this in full extension. My basic setup is that of a C-clamp where I'm able to be able to do this on my own essentially with the help of either one OR technician or one first assist. These are my basic portal sites for this all-inside technique where quadriceps autograft harvest can be seen with that vertical incision, GERDES tubercle and the fibular header mark laterally and then the planned exit point through that AM portal laterally. So you start the case by doing a quick diagnostic scope and what I'm trying to highlight here is that you can see the repair right there at the top of the pouch where I took this full thickness graft and then was able to close it afterwards. So then I begin the step one, how do I optimize visualization? Basic ACL technique portals using this peripatellar media portal, I use a blend instrument, I use a snap in order to open up the portal site and then clean this out. To be a smooth and efficient knee surgeon, Dr. Leprod taught me that you have to be able to flip in and out of both portals without using that trocar introducer and that you have to be able to do this quickly to where you're not fiddle futzing around to optimize your time. This is identifying the ACL tear off the ACL footprint along with some of the mid-substance tear with that AM bundle and then the rest of this is basic initial principles of clearing out the remainder of the ACL, getting that, placing the knee in slight barriers to get that root away to take off the rest of the footprint. Once again, this is all going to be key when you're reintroducing the graft to be able to optimize putting this into the tunnel and so I do a limited notch plasty and then since I will be using that AM portal, we're going to be taking this through the over the top position to make sure that we're going to be able to use that AM portal, take this spinal needle and really use this as to guide your trajectory to make sure that you can get where you want to go so I can get all the way to the back and that I'm above the meniscus to optimize that angle for that hyperflexion. I use microfractural to mark the center of the footprint which I can then lever this spade tip drill that allows for just a button passage for a suspensory device fixation and so once this is in, I do try to ream at least up to 25 millimeters. This can optimize the amount of graft that you want in the tunnel. I've got my suction shaver in here to remove the bone while we're doing this as well as to help clearly identify and visualize how far that you're reaming the tunnel. Once this is reamed, you back this out. I use that low profile guide to avoid the condyle, get the remainder of the bone out at this point to be able to see and visualize the remainder of the tunnel. By getting all that bone out, that's going to allow full seating of the graft into the tunnel. You can see your back wall. You can see that your lateral notch is going to be more than fine to be able to dunk that graft in. Next, when you're drilling the tibia, I use this 3.2 millimeter fluted drill tip because this is extremely rigid and you can predict the length of the tunnel while using it. This is a tip that I got from Dr. Bob Burks when I did the Anna Traveling Fellowship. You use this fluted drill tip and then plan on this going slightly posteriorly but this allows for you to either insert the flip cutter or the retrograde reamer just by hand and then from there, you're able to clear soft tissue from the tunnels. I reamed this back with the tibial guide set on 60 degrees to optimize the tibial length and point out real quickly that I do use that point to point because you can really lever your hand down to even get a few extra millimeters of that tibial tunnel. But it really is just trying to take this shaver and get all of the soft tissue all out and away from the tunnel site because you have to retrograde load the ACL back into this tunnel and so getting all the soft tissue away is extremely important to be able to do that. I also think that we often erred a little bit too posteriorly in where we're placing our tibial tunnel. That obliquity of the graft, as long as you're not going to impinge on the intercondylar notch is important because that controls more of the rotational aspect versus that A to P aspect where we used to see through this trans-tibial tunnel where there was also rotational instability. And so here I'm demonstrating that how we can do this. You can use either some type of cannula to avoid a soft tissue bridge or you can grab the sutures that you need to initially in order to pass this graft. Through this, I was pulling a part of the synovium out of the way in the front but also was utilizing the sutures through our prior drilled tunnels. The blue suture being through the femoral tunnel, the black and white suture through the tibial tunnel and from there quickly raising my hand to be able to keep these separated to where we can then pass the graft into this. So then when we're doing this, this is where the planning of the graft length comes into to the part of the operation. So I initially go for 15 millimeters in, I do use a small C-arm to verify that I'm in and over that lateral cortex. Once this is seated, it does require, this can be a little bit of a fiddle futz factor, this is I think was one of the most frustrating parts of the case initially for me is being able to back load this ACL into the tunnel. And so I make sure I have about 15 millimeters of graft into the tunnel. And then this can either be seated and you can feel the clunk going in or it sometimes requires a blunt instrument to be able to facilitate passage into the tibia. And so this is tensioning it, I'm looking at both portals, I've tensioned this in extension and once this is, you can see this big robust graft, it's tight, the exam is reproducible and you see this go down with very low profile suspensory fixation. With that, I'd like to thank the education team, the opportunity to do this and I appreciate Matt McNutt and Kim Santinello once again for putting this together. Thank you.

ACL reconstruction

quadriceps autograft

surgical technique

patient outcomes

surgical equipment

surgical techniques

Air Force Academy