ACL reconstruction withthe ACUFEX™ DirectorDrill Guide andENDOBUTTON™ CLFixation SystemThomas D. Rosenberg, MD

Knee SeriesTechnique Guide ENDOBUTTON™ CL

Fixation System

*smith&nephew

ACL Reconstruction with the ACUFEX™Director Drill Guide and ENDOBUTTON™ CL Fixation System.

IntroductionIn the late 1980s, Smith & Nephew’s ACUFEXinstrumentation helped standardize ACLreconstruction. In 1999 the Smith & NephewENDOBUTTON CL Fixation Device further simplifiedACL reconstruction and increased initialreconstruction strength.

The Smith & Nephew ACUFEX Director Drill GuideSystems offer a complete system of instruments forthe accurate, reproducible placement and drilling oftibial and femoral tunnels during ACLreconstruction. ACUFEX Drill Guide System featuresinclude:

the ACUFEX Director Guide, which achieves rigidity,accuracy and simplicity with one-handed operation.

the Anti-Impingement Device, which simplifiesmonitoring of the intrachondral notch prior to thecreation of the tibial tunnel.

the 2–5 mm and 3–9 mm offset drill guides, whichfacilitate precise guide pin placement.

the Endoscopic Femoral Aimer with 3 mm or 4 mmoffset, which optimizes femoral positioning forsemitendinosus constructs.

the ENDOBUTTON CL Fixation System, whichconsistently provides very strong and versatileendoscopic femoral fixation utilizing soft tissuegrafts.

the NOTCHMASTER™ Currette, which facilitatesremoval of bone and soft tissue from the notchduring notchplasty.

Notch PreparationIf necessary, perform appropriate notchplasty usingthe Smith & Nephew NOTCHMASTER Curette(Figure 1) or Smith & Nephew NOTCHBLASTER Burr(Figure 2).

Autografts typically require a 2 mm clearance. Theproximal outlet of the notch should not be enlarged;rather, it is carefully identified with the knee at 90°flexion.

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Figure 1

Figure 2

Tibial Tunnel LocationPosition the tibial tunnel using the Smith & NephewACUFEX™ Director Drill Guide as follows (Figure 3):

The remaining distal stump of the torn ACL is themajor orientation guide.

Using the Elbow Aimer: place the tip of the aimer inthe posterior fibers of the ACL footprint. The 2.4 mmguide wire will protrude through the tibial plateauseveral millimeters anterior (depending on the angleof the tibial tunnel) to the elbow of the aimer.

Using the Tip Aimer: place the tip of the aimerexactly at the point where the 2.4 mm guide wirewill protrude through the tibial plateau.

Advance the 2.4 mm guide wire in the preferredposition (Figure 4). The angle of the aimer may beadjusted depending on the graft length. To achievea longer tibial tunnel, increase the angle of theaimer arm.

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Figure 4:

Figure 3

Notch AssessmentBefore drilling the tibial tunnel, use the Anti-Impingement Device to assess the Notch (Figure 5).Place the Anti-Impingement Device over the guidewire and view the knee as it is extended through arange of motion.

If the guide wire is sub optimally positioned, usethe 2–5 mm Offset Drill Guide to reposition it(Figure 6).

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Figure 5

Figure 6

Tibial Tunnel DrillingDrill the tibial tunnel using a standard CannulatedDrill Bit that matches the graft diameter. Advancethe drill bit over the guide wire and drill the tibialtunnel (Figure 7).

Femoral Tunnel LocationThe knee is usually flexed at 90°. Position theendoscopic femoral aimer with the appropriateoffset hook (Figure 8: X mm) at the over-the-topposition, in direct contact with the bony cortex.

Note: When using the ENDOBUTTON CL System forfemoral fixation, break-through of the posteriorfemoral cortex does not compromise fixation. If alonger femoral tunnel is desired (e.g., with anexceptionally long graft), the knee can be flexedslightly less than 90°.

Advance the 2.7 mm passing pin through thefemoral offset guide and drill through the femur untilthe passing pin penetrates the lateral femoral cortex(Figure 8). Feel the 2.7 mm passing pin just underthe skin after it exits the cortex to determine itsposition with respect to the tourniquet.

Femoral Tunnel DrillingSelect an Endoscopic Drill bit which matches thegraft diameter and use it to produce the femoralsocket. Depth is regulated according to the desiredinsertion length. Depth is 9–10 mm greater than thedesired graft insertion, to allow ENDBUTTON devicerotation (Figure 9).

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Femora

lSoc

ket

Femoral insertionlength (ex. 25 mm)

Turning Space(9-10 mm)

Figure 7

X mm

Figure 8

Figure 9

The knee should now be flexed at least 90°. A 2.7 mm Passing Pin and a 4.5 mm Endoscopic Drill are used to produce the passing channel(Figure 10).

An ENDOBUTTON Depth Gauge is used to measurethe total length of the femoral channel (Figure 11).

Note: Bi-socket femoral tunnels may be used withsoft tissue grafts to better reproduce the anatomy ofthe original ACL. For instructions on this techniquesee the Double Bundle ACL Reconstruction using theENDOBUTTON™ CL Fixation System technique guide(REF 10600005).

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Figure 10

Figure 11

Femoral channellength (ex. 60 mm)

Graft PreparationWorking on the GRAFTMASTER™ board, thesemitendinosus graft can be cut into two portions ofequal length, or use semitendinosus and gracilisgrafts.

Each half, or semitendinosus and gracilis, can bedoubled-over to produce a quadrupled constructwhich is pre-sized as shown (Fgure 12).

If desired, pretensioning may be standardized byplacing the graft construct around the TensioningPost (Figure 13), utilizing the Tensiometer (usually 20pounds for 10 minutes).

ENDOBUTTON CL Device SizingThe ENDOBUTTON CL device length is determinedby the difference between the total femoral channellength and the desired femoral graft insertionlength. If this falls between two ENDOBUTTON CLdevice sizes, round-up or down to the closer size.

Note: The ENDOBUTTON CL device is currentlyavailable in 5 mm increments. If the required sizefalls outside the available range or if theENDOBUTTON CL device is not available, seeAppendix A.

Pass the grafts through the continuous loop andload the construct into the ENDOBUTTON Holder.

Place a line on the graft 6 mm distal to the totalchannel length. This line indicates the rotation pointfor the ENDOBUTTON CL (Figure 14).

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Figure 13

Figure 14

Figure 12

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Graft PassageAttach a #5 polyester braided suture to one outsidehole of the ENDOBUTTON device to lead and passthe ENDOBUTTON device. Attach a trailing #2polyester braided suture to the opposite outsidehole of the ENDOBUTTON device to rotate theENDOBUTTON device as it exits the anterolateralfemoral cortex. Both sutures are passed throughthe eyelet of a passing pin (Figure 15 inset).

The passing pin is used for suture passage bypiercing the quadriceps and skin proximally (Figure 15). The #5 suture is pulled first, advancingthe ENDOBUTTON/graft complex into the femoraltunnel. When the marking line reaches the internalfemoral aperture, the trailing #2 suture is pulled,rotating the ENDOBUTTON device immediatelyexternal to the femur (Figure 16).

Hold the ENDOBUTTON device perpendicular to thefemoral cortex and pull back on the graft, lockingthe ENDOBUTTON device on the outer femoralcortex. Secure fixation should be felt at that pointwith the “blue line” retreating 6 mm.

Figure 15

Figure 16

#2 Suture

#5 Suture

Graft TensioningCycle the knee through a range of motion prior totibial fixation to pretension the graft (Figure 17).

Tibial FixationTension the graft and fix as desired, i.e., with aSmith & Nephew interference screw, tying over ascrew and washer, or both (Figure 18). Knotting isusually achieved at 20–30° of knee flexion.

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Figure 17

Figure 18

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Appendix AENDOBUTTON™ FixationDevice Technique (withknotted connector)Attach the ENDOBUTTON Tapeusing the ENDOBUTTON Holder.A doubled surgeon’s knot is used(Figure 19). The ENDOBUTTONTape length plus the insertionlength combine to equal the totalchannel length.

Figure 19

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Appendix BPatellar Tendon GraftPreparation and Techniquewith the ENDOBUTTONFixation DeviceAttach the graft through the twocentral holes of theENDOBUTTON device using theGRAFTMASTER™ Board (Figure 20).

Connect the ENDOBUTTONdevice to the bone block usingeither #5 sutures, or 4–6 mmwide polyester tape. The desiredlength of the graft insertionadded to the span of the suturesmust equal the total channellength (Figure 21).

Lead and pass the ENDOBUTTONdevice using a #5 suture. Atrailing #2 suture is later used torotate the ENDOBUTTON as itexits the anterolateral femoralcortex.

The Drill Passing Pin (2.7 mm x15") is used for passage of thegraft, piercing the quadriceps andskin proximally.

Drilling perforation of theposterior cortex does notcompromise graft fixation andmay optimize femoral graftplacement. Patellar tendon grafts may be seated moreproximally with the ENDOBUTTONdevice, eliminating graftprotrusion from the tibial tunnel.

An interference screw can beused for distal fixation (Figure 22).

Note: For more information, see the ACL reconstruction withbone-tendon-bone transplantsusing the ENDOBUTTON CL BTBFixation System technique guide (REF 10615040).

Figure 20

Figure 21

Figure 22

™Trademarks of Smith & Nephew. Certain marksregistered U.S. Patent & Trademark Office.©1999, 2005 Smith & Nephew, Inc. All Rights Reserved.

Printed in USA 05/05 10600026 Rev. A

EndoscopySmith & Nephew, Inc.Andover, MA 01810 USA

www.smith-nephew.com978 749 1000978 749 1108 Fax800 343 5717 U.S. Customer Service

Additional InstructionPrior to performing this technique,consult the Instructions for Usedocumentation provided withindividual components — includingindications, contraindications,warnings, cautions, and instructions.

Courtesy of Smith & Nephew, Inc.,Endoscopy Division

Caution: U.S. Federal law restricts this deviceto sale by or on the order of a physician.