Secondary Logo

Journal Logo

Tips and Pearls

Addressing the Complications Associated With the Use of Arthrex TightRope RT in Anterior Cruciate Ligament Reconstruction

Maredupaka, Siddhartha MS (Orthopaedics)*; Kumar, Vijay MS (Orthopaedics), MRCS (Glasgow); Nayak, Mayur MS (Orthopaedics); Yadav, Rahul MS (Orthopaedics)

Author Information
doi: 10.1097/BTO.0000000000000420
  • Free

Abstract

Anterior cruciate ligament tear is a common soft tissue injury frequently treated by arthroscopic anterior cruciate ligament reconstruction (ACLR) with an autologous hamstring graft. The graft fixation, which is commonly achieved either with aperture or suspensory fixation devices, is of critical importance in ACLR during the immediate postoperative period until the biological fixation occurs in the bone tunnel.1

TightRope Reverse Tension (TRT) is a commonly used suspensory fixation device that is comprised of a 13-mm long titanium button along with a polyethylene suture spliced to create an adjustable quadrupled loop. In addition, it contains blue passing sutures for the advancement of the graft-loop construct, side suture for flipping the button, and the white tensioning sutures to reduce loop length and to advance the graft. TRT has distinct advantages compared with fixed-length devices, such as ease of using single-loop size for all patients, obviating the need for precise calculations, complete filling of femoral sockets, and the ability to retention even after tibial fixation.2–4 Moreover, it has the provision of pulling the tensioning strands in the same direction as graft advancement, an innovation from the previous TightRope. However, there are certain potential complications associated with its use that might lead to ultimate failure of the surgery despite adhering to standard precautionary measures. With extensive first-hand experience in using TRT at our center, we describe various intraoperative complications that can occur with its use and techniques to prevent and manage them.

SURGICAL TECHNIQUE

We routinely use TRT for femoral fixation in ACLR. The graft preparation entails making 2 markings; one on the loop and the other on the graft (Figs. 1, 2). The first mark made on the loop corresponds to the length of the femoral tunnel measured intraoperatively and is made measuring from the distal tip of the button, with the button being held in line with the loop. This mark on reaching the internal opening of the femoral socket indicates that the button is ready to be flipped (Fig. 1). The second mark made on the graft from its femoral end corresponds to the length of the femoral socket (Fig. 2) and indicates the endpoint for graft tensioning.5 Although TRT allows the femoral sockets to be prepared either by the outside-in technique with Flip Cutter or inside-out fashion, we routinely use the inside-out technique through the accessory anteromedial (AM) portal for creation of the femoral tunnel. Care is taken to preserve 7 to 10 mm corticocancellous bridge of bone laterally. The tibial tunnel is drilled in a standard fashion.6 No. 5 Ethibond (Ethibond; Ethicon, Somerville, NJ) is then used to shuttle the passing sutures from the tibial tunnel into the femoral socket. The button is routinely visualized entering the femoral socket and securely flipped when the marking on the loop reaches the entrance of the femoral tunnel. The flipping of the button onto the lateral femoral cortex can be checked by feedback obtained by pulling the tibial tails of the graft, following which the graft is advanced into the femoral socket by alternately pulling on the tensioning strands. A C-arm image is obtained after the graft is advanced into the femoral socket and before the tibial interference screw (Arthrex Inc., Naples, FL) is placed to confirm that the button is lying along the lateral femoral cortex. The graft can be retensioned following tibial fixation for improving graft-bone interface within the tunnel. Although the surgical workflow can proceed smoothly in experienced hands, surgeons new to TRT need to be aware of the potential intraoperative complications, precautionary measures to avoid them, and bailout strategies on occurrence of such events (Table 1).

FIGURE 1
FIGURE 1:
Mark made on the loop (black line) from the distal tip of the button kept in line with the TightRope Reverse Tension (TRT) loop, which corresponds to the length of the femoral tunnel. This mark, on reaching the internal opening of the femoral socket, indicates that the button is ready to be flipped.
FIGURE 2
FIGURE 2:
Mark made on the graft (black line) from the femoral end corresponds to the length of the graft in the femoral socket. TRT indicates TightRope Reverse Tension.
TABLE 1 - Presenting the Potential Complications With the Use of TightRope RT and Their Bailout Surgical Strategies
Potential Complications With TightRope RT Bailout Surgical Techniques
1. The button is stuck in the guide-pin hole 1. Controlled push using a 2.4-mm guide pin
2. If this fails to address the button, which is obliquely jammed within the pinhole, leave the button as such and use tensioning strands to supplement the construct by tying them around a screw
2. The button is pulled too far laterally and flipped over the soft tissue, identified intraoperatively 1. Incision and exposure of the implant and lateral femoral cortex followed by clearing the interposed soft tissue
2. Atraumatic seating of the button using knot pusher
3. Tensioning the graft and tying of a knot over the button
3. The button is pulled too far laterally and flipped over the soft tissue, identified postoperatively 1. Incision and exposure of the remnant tensioning strands, malpositioned button, and lateral femoral cortex followed by clearing the interposed soft tissue
2. Atraumatic seating of the button using knot pusher
3. Tensioning the graft using Kelly clamps over the tensioning sutures and additional tying of a knot over the button or under a post (screw with washer)
4. Impaction of the button into the corticocancellous bone bridge or femoral tunnel during cycling 1. If adequate graft inside the socket with well-impacted button, retain the graft-loop construct as such and augment posttie around a screw
2. If the button is severely impacted with insufficient graft inside the socket
a. Dissociate the graft from the TightRope RT
b. Removal of the loop and button through the lateral approach
c. Retrieval of the graft from the tibial end
d. Use a biointerference screw for femoral fixation
e. Alternately, TightRope ABS suture can be looped over the Arthrex TightRope ABS
5. Complete loop breakage during cycling the knee 1. Remove the graft from the knee
2. Remove the button and the loop through the lateral approach
3. Use a new TightRope RT or a biointerference screw
ABS indicates Attachable Button System; RT, Reverse Tension.

Scenario 1: The Button is Stuck Within the Guide-pin Hole

The button of the TRT can be stuck inside the guide-pin hole either temporarily during graft passage or when the graft is pulled from the tibial end for tactile feedback of the seating of the button. To avoid this complication, the button is only flipped after its complete disappearance in the arthroscopic end on the visualization of the femoral tunnel, as in Figure 3, along with close monitoring of markings made on the loop. In the event of occurrence of this complication during graft passage, a 2.4 mm guide pin (Arthrex Inc.) engaged on the depression of the button can be used to safely push it past the guide-pin hole, provided the tunnel is drilled through an AM portal7 (Fig. 4). However, it might fail to address a tightly jammed button in 2 situations. First, when the button is jammed obliquely inside the guide-pin hole, a situation that occurs when the graft is pulled from the tibial end before it is completely flipped, it is difficult to engage the guide pin. Second, in cases wherein the femoral tunnel is prepared in an outside-in fashion, it is difficult to get the right trajectory for guide-pin insertion. In such circumstances, no further attempt is made to push the button or forcefully pull the passing sutures to avoid damage to the cortical bone bridge. Instead, a 4- to 5-cm longitudinal incision is made on the skin; after soft tissue dissection, the iliotibial band is incised and the vastus lateralis is split along the direction of its muscle fibers to expose the guide-pin hole and the adjoining femoral cortex. The tightly stuck button is left as such, and tensioning strands are alternately tensioned to ensure complete filling of the socket with the graft. Following this, the tensioning sutures are securely tied under a 4.5-mm cortical screw and washer, inserted perpendicular to the lateral femoral cortex at a distance of 2 to 3 cm from the femoral tunnel (Fig. 5). This serves as a supplement to the button stuck in the pinhole, besides eliminating the chances of any further button slippage.

FIGURE 3
FIGURE 3:
Arthroscopic visualization of the passage of the button. Reprinted from Nag and Gupta.7 Reprinted from Arthroscopy Techniques, 1, Nag HL & Gupta H, Seating of TightRope RT button under direct arthroscopic visualization in anterior cruciate ligament reconstruction to prevent potential complications, 83-85, 2012, with permission from Elsevier. All permission requests for this image should be made to the copyright holder.
FIGURE 4
FIGURE 4:
Controlled pushing of the button with a 2.4 mm guide pin, engaged into the depression found at the end of the button. Reprinted from Nag and Gupta.7 Reprinted from Arthroscopy Techniques, 1, Nag HL & Gupta H, Seating of TightRope RT button under direct arthroscopic visualization in anterior cruciate ligament reconstruction to prevent potential complications, 83-85, 2012, with permission from Elsevier. All permission requests for this image should be made to the copyright holder. RT indicates Reverse Tension.
FIGURE 5
FIGURE 5:
Tying the tensioning strands around a screw and a washer, to supplement the tightly stuck button in the pinhole.

Scenario 2: The Button is Pulled too far Laterally and Flipped Over the Soft Tissue; Identified Intraoperatively

This occurs due to excessive pull on the passing sutures while advancing the graft-loop construct through the femoral tunnel. The following precautionary measures are helpful in averting such an event. First, constant traction needs to be maintained on the tibial tails of the graft during graft advancement. Second, excessive pulling of the passing sutures should be avoided once the mark made on the loop reaches the entry of the femoral tunnel. Third, the flipping of the button over the lateral femoral cortex can be indirectly confirmed by pulling the passing suture with counter pressure on the graft from the tibial end. In case the button is flush against the bone, the passing suture will not glide easily, as it is pressed under the button. Last, an intraoperative anteroposterior radiograph with the knee in 15 to 20 degrees flexion is recommended to confirm the appropriate position of the button (Fig. 6). The bailout strategy in such an event involves open repositioning of the button by exposing the lateral femoral cortex (mentioned above). Identification of the button can be carried out through tracing the tensioning strands, which are not yet cut at this stage. The tensioning strands are then pulled alternately to get the button back to the bone. In case, the tensioning sutures lock prematurely, posing difficulties with getting the button to the bone, a knot pusher (Arthrex Inc.) is used over the tensioning suture to atraumatically seat the button over the lateral femoral cortex. In addition, tying the tensioning strands over the button to augment the construct eliminates the chances of any further loop slippage.

FIGURE 6
FIGURE 6:
Intraoperative C-arm image confirming the position of the button over the lateral femoral cortex. RT indicates Reverse Tension.

Scenario 3: The Button is Pulled too far Laterally and Flipped Over the Soft Tissue but Missed Intraoperatively and Identified in Follow-Up X-Rays at the Postoperative Clinic Visit

A button pulled too far laterally into the soft tissues, could be missed intraoperatively, if C-arm imaging is not routinely used to check the position of the button. Observing careful surgical steps, as described above, and using an intraoperative anteroposterior radiograph of the knee in slight flexion can avoid this complication (Fig. 7). The bailout strategy in such a scenario would involve lateral exposure to the distal femoral cortex as (as mentioned above) with a 4- to 5-cm incision over the previous exit site of the guide pin. As the tensioning sutures have been cut at the skin in the index procedure, 4 to 5 cm of the remaining suture strands should be identified by careful dissection along with the button lying either in the substance of the vastus lateralis or on the iliotibial band. The soft tissue around the button is atraumatically cleared using a blunt artery forceps, and a knot pusher is subsequently passed over the tensioning strands to gently push and reposition the button onto the lateral femoral cortex. Using sharp instruments to reposition the button can cause an iatrogenic nipping to the loop or the tensioning strands and should be avoided. Once the button is appropriately positioned over the lateral femoral cortex (Fig. 8), both ends of the tensioning suture are secured to Kelly forceps and pulled one at a time, 1 cm in each direction to recreate the tension in the graft (Fig. 9). To eliminate the chances of loop slippage, the construct is augmented by securely tying the tensioning sutures under a screw and washer (Fig. 10) or as a knot over the button, when the length of the tensioning strands is deemed inadequate. Alternately, one can also pull on the remaining sutures and place an interference screw in the femoral socket if the socket is drilled through an AM portal, after ensuring the adequate length of the graft in the femoral socket.

FIGURE 7
FIGURE 7:
Postoperative x-ray showing a laterally malpositioned button. RT indicates Reverse Tension.
FIGURE 8
FIGURE 8:
Visual confirmation of the seating of the button over the lateral femoral cortex. TRT indicates TightRope Reverse Tension.
FIGURE 9
FIGURE 9:
Securing the tensioning sutures to artery forceps to prepare for tensioning the graft. TRT indicates TightRope Reverse Tension.
FIGURE 10
FIGURE 10:
Augmenting the repositioned button by tying the tensioning strands around a screw inserted perpendicular to the femoral cortex. TRT indicates TightRope Reverse Tension.

Scenario 4: Transverse Impaction of the Button into the Corticocancellous Bone Bridge, due to Excessive Force From the Tibial End During Cycling

The prerequisite for suspensory fixation is the availability of good bone stock to counter the forces under the button, especially before the graft is fused with the bone tunnels. Hence, cautious use of suspensory fixation devices is advised in conditions of poor bone quality, such as osteoporosis, or in the setting of revision ACLR. In this distinct context, the button indents the lateral femoral cortex due to the pulling force exerted on the tibial tails of the graft during cycling and transversely impacts into the bone bridge, as it has already been flipped horizontally. In such an event, it is recommended to arthroscopically check the extent of distal movement in the graft using the markings made on the graft followed by C-arm imaging. If it is identified that there is sufficient graft inside the femoral tunnel, and the button is well impacted, as indicated by no further movement on pulling the graft from the tibial end or on further cycling, the graft-loop construct can be retained as such. However, it is recommended to use an augmentation posttie using a 4.5-mm cortical screw and a washer (Fig. 11) to decrease the stresses on the button and to avoid further impaction within the femoral tunnel.

FIGURE 11
FIGURE 11:
Augmenting the transversely impacted button in the guide-pin hole by tying the tensioning sutures around a screw and washer. TRT indicates TightRope Reverse Tension.

In cases of a more severe impaction of the button into the tunnel with complete incompetence of the bone bridge, the stability of the graft loop construct is jeopardized along with an insufficient amount of graft inside the socket (Fig. 12). In such an event, it is recommended to expose the lateral femoral cortex and pull the button and the passing sutures to recreate the tension in the graft, following which an interference screw (Arthrex Inc.) is used for graft fixation. However, this strategy can only be used when the tunnel is prepared in an inside-out fashion through an AM portal, as it is difficult to get the right trajectory for screw insertion in outside-in tunnel preparation. Alternatively, the graft can be disassociated from the TRT by getting the button slightly beyond the lateral cortex and cutting the loop beneath the button, following which the graft is retrieved from the tibial end. The femoral end of the graft is then looped with TightRope Attachable Button System (ABS) suture and additional fiber wire fixation sutures, which are used to tie over an Arthrex TightRope ABS button over the lateral femoral cortex (Fig. 13). With the availability of numerous sizes, shapes, and slot options, the TightRope ABS is a good alternative in the face of such a complication.

FIGURE 12
FIGURE 12:
More severe impaction of the button with an insufficient amount of graft in the socket. TRT indicates TightRope Reverse Tension.
FIGURE 13
FIGURE 13:
Use of Tightrope Attachable Button System to address severe impaction.

Scenario 5: Complete Loop Discontinuity or Breakage During Cycling the Knee

Although complete loop discontinuity is rare, it is critical to be aware of the causes of this event, as it damages the implant beyond the point of salvage. Damage to the loop can possibly occur when it is nipped during graft preparation and frayed during the passage of the graft, by the sharp edges of the bone debris generated while drilling the femoral and tibial tunnels.6 Debridement of the bone debris in the tibial tunnel by inserting an arthroscopic shaver from outside to in and from the femoral tunnel through AM or accessory medial portal is a useful precautionary measure to avoid loop damage. Furthermore, careful graft preparation and avoiding undue forces on the tibial end during cycling of the knee can avert this complication. On encountering such a situation wherein the implant is damaged beyond the point of salvage, it is recommended to remove the graft and use a new TRT. Alternatively, an interference screw (Arthrex Inc.) can also be used, if the femoral tunnel is prepared using the inside-out technique.

DISCUSSION

TRT, an adjustable-loop second-generation suspensory fixation device, has the advantage of incremental graft advancement and the ability to retention the graft even after the tibial fixation, ultimately leading to a stable final construct. However, there are a few technical considerations with regard to its use that one should be aware of during the surgery.

Nag and Gupta7 reported arthroscopic visualization of the button passage and controlled pushing of the button with a guide pin to prevent the button from getting stuck in the guide pin hole (Figs. 1, 2). However, this measure often proves to be unsuccessful when the button is firmly jammed rather obliquely in the pinhole. In such an event, tying of the tensioning sutures around a 4.5 mm cortical screw with washer used as a post (Fig. 3) is a reasonable augmentation to the jammed button.

By the virtue of its long loop length, there is a tendency for the button of TRT to be pulled too far laterally and flipping within the soft tissue. To avoid this complication, previously published techniques described precautionary measures such as arthroscopic visualization of the flipping of the button in the lateral gutter along with capsulotomy and debridement of the lateral epicondylar area by an arthroscopic shaver.8,9 Such techniques need considerable arthroscopic skills and experience. These techniques have been reported to be more effective in outside-in drilling of the femoral tunnel than in transportal tunnel preparation. In addition, self-flip technique by Harato et al10 relies entirely on tactile feedback with no direct confirmation of the button position. Our technique, on the other hand, involves repositioning under direct visualization and is useful in transportal and in outside-in tunnel preparation. In addition, our technique addresses the surgical approach to salvaging TRT when the button is already trapped in the soft tissue.

Although tying the tensioning strands around a screw (used as a post) to augment an impacted button is described in the literature,11 our technique of addressing severe impaction and insufficient graft in the tunnel by using an Arthrex ABS or an interference screw is a good alternative to salvage the surgery. The final strategy for complete loop disruption, although it does not salvage the implant, is that the described precautionary measures during graft preparation and passage should be borne in mind. Every attempt should be made to adhere to the precautionary measures and avoid the aforementioned complications, but, in the face of such events, techniques described in this article are of great help.

CONCLUSIONS

The present article deals with the intraoperative challenges a surgeon might face while using TRT, its precautionary measures, and management. We believe our approach and recommendations would improve the surgical workflow in achieving a stable fixation of the graft in the femoral tunnel. This would greatly benefit the surgeons, especially those who are new to the use of this implant.

REFERENCES

1. Brand J, Weiler A, Caborn DN, et al. Graft fixation in cruciate ligament reconstruction. Am J Sports Med. 2000;28:761–774.
2. Barrow AE, Pilia M, Guda T, et al. Femoral suspension devices for anterior cruciate ligament reconstruction: do adjustable loops lengthen? Am J Sports Med. 2014;42:343–349.
3. Boyle MJ, Vovos TJ, Walker CG, et al. Does adjustable-loop femoral cortical suspension loosen after anterior cruciate ligament reconstruction? A retrospective comparative study. Knee. 2015;22:304–308.
4. Lubowitz JH, Ahmad CS, Anderson K. All-inside anterior cruciate ligament graft-link technique: second-generation, no-incision anterior cruciate ligament reconstruction. Arthroscopy. 2011;27:717–727.
5. Lubowitz JH. All-inside anterior cruciate ligament graft link: graft preparation technique. Arthrosc Tech. 2012;1:165–168.
6. Colombet P, Graveleau N. An anterior cruciate ligament reconstruction technique with 4-strand semitendinosus grafts, using outside-in tibial tunnel drilling and suspensory fixation devices. Arthrosc Tech. 2015;4:507–511.
7. Nag HL, Gupta H. Seating of TightRope RT button under direct arthroscopic visualization in anterior cruciate ligament reconstruction to prevent potential complications. Arthrosc Tech. 2012;1:83–85.
8. Sonnery-Cottet B, Rezende FC, Martins Neto A, et al. Arthroscopically confirmed femoral button deployment. Arthrosc Tech. 2014;3:309–312.
9. Kang SG, Lee YS. Arthroscopic control for safe and secure seating of suspensory devices for femoral fixation in anterior cruciate ligament reconstruction using three different techniques. Knee Surg Relat Res. 2017;29:33–38.
10. Harato K, Niki Y, Toyoda T, et al. Self-flip technique of the TightRope RT button for soft-tissue anterior cruciate ligament reconstruction. Arthrosc Tech. 2016;18:391–395.
11. Choi SH, Ha JK, Jun DJ, et al. Additional post-tie for unstable femoral suspensory fixation during anterior cruciate ligament reconstruction using TightRope ® RT: clinical reports on 3 cases. Arthrosc Orthop Sports Med. 2017;4:34–38.
Keywords:

TightRope RT; suspensory fixation; complications; bailout techniques; anterior cruciate ligament; reconstruction; single bundle

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.