Arthroscopy is a minimally invasive type of surgery where in small incisions are made in the knee to investigate what is causing knee problems and treat them. Arthroscopy helps diagnose arthritis and inflammation of the knee and also aids doctors to repair damaged tissue and cartilage. Compared with open surgery, arthroscopy is less painful, carries less risk of infection, and has a faster recovery time. Here we have explained the procedure for an Anatomical ACL Reconstruction and Meniscal Cinch.

• Anatomical ACL Reconstruction
  
  
• Meniscal Cinch
  
  

Anatomical ACL Reconstruction

Double Bundle

ACL Reconstruction Advantages:

• More anatomical reconstruction of the anteromedial and posterolateral bundles of the ACL
  
• Maximizes graft stiffness with true joint line fixation
  
• Substantially increases femoral and tibial graft fixation strength compared to standard interference screws.
  
• Maintains graft tension during tibial screw fixation
  
• True joint line fixation reduces tunnel widening
  
• Replaces the need for double tunnel surgery using reproducible transtibial techniques and instrumentation.
  
  

Surgical Technique:

Graft Preparation

A double hamstring autograft or tibialis tendon allograft (illustration below) of a minimum length of 140 mm is preferred for the double bundle ACL technique. The midline is marked and a 20 mm whipstitch of #2 FiberWire® is placed on each side of the graft midline. Avoid suturing across the midline to allow for folding of the graft during tunnel insertion. A 20 mm whipstitch is placed 50 mm from the proximal end of the graft to enhance tibial RetroScrew fixation. A #5 FiberWire graft passing suture is looped around the midline.

	Femoral and tibial tunnels are prepared in standard transtibial fashion. The femoral tunnel orifice is notched at the 10:00 and 4:00 positions for a left knee, for the anteromedial and posterolateral bundles. The anterior and posterior tibial tunnel orifices are notched using a 5 mm wide Retro Tunnel Notcher.
	The graft is passed, inserting the folded section into the femoral tunnel. A #2 FiberStick™ is preloaded in the RetroScrew driver with 2 cm length extending from the tip. The driver is inserted through the tibial tunnel anterior to the graft. The FiberWire end is retrieved and pulled out the anteromedial portal. The FiberStick is inserted through the head and knotted at the tip of the Femoral RetroScrew with at least three half-hitches. The Femoral RetroScrew is snapped into the end of the Shoehorn™ Cannula. The cannula is inserted into the anteromedial portal and the cannula obturator is used to push the screw into the joint
	The FiberStick is pulled up, mounting the Femoral RetroScrew on the driver tip. Care should be taken to remove soft tissue from the driver/screw interface prior to seating of the screw. The RetroScrew is fully inserted onto the driver when the laser line is flush with the head of the screw. Grasp the FiberStick suture at the tip of the screw and remove the FiberStick out the anteromedial portal.
	Pull the graft distally to visualize the whipstitching and position the Femoral RetroScrew between the two graft strands. Slowly pull the graft fully into the femoral socket while advancing the screw tip into the femoral tunnel between the graft strands. A probe may be used to orient the two bundles anatomically into the respective notches. The distal end of the whipstitching should be flush with the tunnel prior to screw insertion.
	Pull the graft distally to visualize the whipstitching and position the Femoral RetroScrew between the two graft strands. Slowly pull the graft fully into the femoral socket while advancing the screw tip into the femoral tunnel between the graft strands. A probe may be used to orient the two bundles anatomically into the respective notches. The distal end of the whipstitching should be flush with the tunnel prior to screw insertion.
	The knee is cycled and the screwdriver reloaded with a #2 FiberStick and reinserted up the tibial tunnel anterior to the graft. The proximal end of the FiberStick suture is retrieved and pulled out the anteromedial portal.
	The FiberStick end is passed through the tip of a Tibial RetroScrew equal to the tibial tunnel diameter and a Mulberry knot is tied behind the round head of the screw. The Tibial RetroScrew is snapped into the end of the Shoehorn Cannula and the cannula inserted into the anteromedial portal. The cannula obturator is used to push the screw into the joint.
	The Tibial RetroScrew is mounted onto the screwdriver tip by pulling on the FiberStick suture. Remove soft tissue from the screw/driver interface prior to seating of the screw. The screw is fully inserted on the driver when the laser line is flush with the tip of the screw. The FiberStick is wrapped around the driver handle posts to secure the screw for retrograde insertion.
	While fully tensioning the graft in approximately 20˚ of knee flexion, the Tibial RetroScrew is inserted counterclockwise, anterior to the graft under full visual control. Insertion is completed when the round head of the screw is slightly countersunk with the tibial tunnel orifice.
	Grasp the FiberStick at the knot and pull the FiberStick out the anteromedial portal.
	Secondary screw fixation of the graft in the tibial tunnel may be performed by inserting a Femoral RetroScrew into the distal end of the tibial tunnel. Bi-cortical fixation of the graft in the tibial tunnel provides maximum graft fixation strength, creates a blood-rich healing environment in the tunnel between the two screws and may reduce post-op soft tissue hematoma.

Tibial RetroScrew Advantages:

• Inverted, retrograde screw insertion provides maximum fixation in proximal cortical bone
• RetroScrew is inserted in the same direction as graft tensioning
• Round screw head at joint line protects graft against abrasion
• RetroScrew can be accurately placed anterior to the graft
• Full thread diameter fixation at tunnel orifice maximizes graft stiffness
• Inhibits synovial fluid leaching into tunnel, reducing tunnel widening
• Distal tunnel secondary backup fixation options
• FiberStick tether facilitates one step intraarticular screwdriver mounting

Femoral RetroScrew Advantages:

• In-line insertion assures parallel placement to the graft and femoral tunnel
• Thin transtibial tunnel screwdriver used for femoral and tibial screw from the same position
• FiberStick tether facilitates one step intraarticular screwdriver mounting
• Eliminates complications associated with screw insertion from an anteromedial portal
• Backup fixation option at tibial tunnel orifice

Why Multiple Meniscal Repair Options?

The Comprehensive Solutions to Meniscal Repair provides orthopaedic surgeons unique options based on tear patterns, neurovascular safety and surgical time constraints.

All-inside, inside/out and outside/in technique options are essential to safely address every anatomical meniscal tear pattern encountered during arthroscopy.

Meniscal Cinch


The Arthrex Meniscal Cinch allows surgeons to consistently repair meniscus tears with an all-inside arthroscopic technique eliminating the need for accessory incisions required for traditional inside/out techniques that often result in additional morbidity. Based on the tear pattern and location, the Meniscal Cinch gives surgeons the option of horizontal or vertical mattress repair with 2-0 FiberWire suture. The preset sliding knot and the FiberWire properties create a secure, low profile knot that can be countersunk into the meniscus. Depending on exact location and pattern, posterior horn tears can be repaired through standard ipsilateral or contralateral arthroscopy portals. The Meniscal Cinch is placed through the contralateral portal for tears involving the body of the meniscus. Some anterior horn tears can also be repaired using an accessory contralateral portal.

	The Meniscal Cinch is designed to be used through a low arthroscopic portal, near the surface of the tibia. Use the Measurement Probe or the graduated tip of the Meniscal Cinch cannula to measure the approximate distance from the entry point of the implant to capsule. Note: Each line on the graduated probe tip (a) represents 2 mm.
	Set the depth stop on the Meniscal Cinch handle by squeezing the tips together and sliding the depth stop forward. Set the depth stop to a distance equal to the measurement in step one. Note: Each line on the cinch handle represents 2 mm.
	A Shoehorn Cannula may be placed into the working portal before inserting the Meniscal Cinch device. Place the tip of the Meniscal Cinch cannula near the tear. The tip of the cannula may be used to reduce the tear prior to deployment of the first trocar (a). Alternatively, the tip of the first trocar may be advanced past the tip of the cannula to be used to reduce the tear (b). Note: Never pull the trocar back into the cannula after it has been advanced, as this could prematurely deploy the implant.
	Once the tip of the trocar is advanced into the meniscus, the cannula is retracted slightly off the articular surface of the meniscus. Advance the first implant through the meniscus by pushing trocar #1 until the trocar handle makes contact with the depth stop and the cannula restson the surface of the meniscus.
	Remove trocar #1 from the cannula completely. A slight downward force on trocar #1 during removal will ensure that it does not interfere with trocar #2.
	Push down on trocar #2 to release it from the holding position. Move the tip of the cannula to the second insertion point over the meniscus.
	Advance trocar #2 forward by pushing the trocar handle forward. Once the tip of the trocar is advanced into the meniscus, the cannula is retracted slightly off the articular surface of the meniscus. Advance trocar #2 through the meniscus until the trocar handle makes contact with the depth stop and the cannula rests on the surface of the meniscus. Note: Suture slack created by advancing trocar #2 may be reduced by gently tensioning external suture near the handle.
	Remove trocar #2. Remove the Meniscal Cinch from the joint.
	Place the external suture through the tip of the Knot Pusher/Suture Cutter. Push the knot while pulling tension on the free end of the suture. Advance the knot until countersunk into the meniscal tissue. Hold firm tension on the suture. Advance the trigger on the handle of the Knot Pusher/Suture Cutter to cut suture.
	Remove the cutter. Alternatively (a): A vertical mattress stitch may be placed by inserting the implants in a vertical orientation.
Knee Surgery Rehab | Knee Arthroscopy Recovery Dr. Kevin Murphy, M.D. is a Board Certified orthopedic surgeon who specializes in minimally invasive knee surgery, knee rehab, knee acl surgery, knee arthroscopy recovery, hip surgery and shoulder surgery in Jacksonville Florida.