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Recorded Surgical Demonstrations - AOSSM/POSNA Ped ...
3. ACL-ITB
3. ACL-ITB
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Ben Hayward the Melissa Castino from Boston to show us their technique on the use of the iliotibial band For ACL reconstruction Ben. Can you hear me? I can Can you hear me? We got you loud and clear. Okay All right. Thanks Henry And thanks for helping with this Melissa. I should just note that a great video Prepared by Melissa in the five-minute sort of talks that you guys have access to is on this technique as a sort of follow-up reference, so You know, I would say this is by far my favorite procedure in orthopedics and and one of the reasons I went into pede sports when Allow McKellan and Coker's study came out in 2005. I thought it was fascinating the way they could preserve The growth and yet stabilize the knee and the numbers were great so so I really dove in to try and understand this and and We now all kind of do a lot of them and it's nice because it's low cost and there's not really many implants at all So there's no hardware in the knee at the end of the day and it's a very sort of biologic or all biologic kind of technique But when we feel these knees, they're very stable at the end of the day both right after the case and then down the line So what we first do once our pivot is positive is we approach the lateral aspect of the knee And so we make our incision if we close this basically meet a lip or lateral epicondyles right here So I extend from the lateral epicondyle in an oblique fashion towards the superior border of the IT band Which you can see here posterior borders here It's often a little more posterior than you think so always sort of cheat your retractors sort of around the bend posteriorly and then Here's Gertie's tubercle so you can see the outline of the IT band Before I forget, you know, it's a standard lateral portal the medial portal inframedial portal I always make a little more medial and that allows me to get a good angle around the lateral femoral condyle with my Passing clamp which will show you how we do later And then the incision is a sort of a standard ACL incision where you might harvest a hamstring, but possibly a touch more proximal That's where we affix on the tibia and so we've made our initial cuts here We've made our initial cuts on the Close to the superior and inferior borders of the IT band I made a dot where I thought the posterior border was here and a dot where I thought the anterior border where it kind of is confluent with the Vastus lateralis fascia, it's sometimes hard to differentiate IT band versus fascia So take some time with that and then I go kind of the middle 80% or so So this one centimeter strip that was originally described. It's always a little bit longer than that and sometimes dr Michele will take kind of the whole IT band so then I'll put a clamp or a device here and then I'll try to separate the IT band from the capsule distally and from the Vastus fascia proximally and sometimes it's stuck and so you may need to pull back here and then take your Bovee or a knife and peel it off of the underlying vastus fascia because you do want separation So one technique is to take a cob and really slide up Along the sub-q tissue and separate the IT band as far up as you can go because we really harvest a long graft People ask how long it's got to be at least sort of 150 to 180 I tend to go about 200 and I don't think it's a big deal to take more of the IT band approximately there's a big sort of Issue or people get worried about the the defect in the IT band, but we've done a lot of studies on IT band function suggesting that There's really no big deficits both on the short term in the long term So these folks actually recover from an ACL return-to-play perspective better than any other reconstruction that we do So then the harvest and so we'll take these Meniscus tomes. So these are old-school meniscus knives that don't get used on the meniscus anymore, but are nice for this And these are part of one of the vendors sets where they're doing all epiphyseal with some of the equipment in the set and then this technique with other equipment in the set and So this meniscus tome I would aim Posteriorly and slide up the knee and so we've done that right along that IT band and then the other direction Slide and I put the longer arm of this kind of Deep and so we slide up and so it's a tactile kind of feel there where you get the resistance of the IT band And then I tell the fellows there's sort of three tricky parts of the case. And this is the first one Technically tricky that is so so the I put my finger around the IT band for counter pressure for counter traction and then I slide this long curved meniscus tome up and Then I lever it down to cut through and transect the IT band proximally in the thigh a lot of people have taken to just putting a little incision there and just Transacting it with a knife and it's a tiny little thigh incision that that is not a cosmetic issue So so I think in your early in practice or early with use of this technique, that's very reasonable some people just prefer it all together and there is like a Harvester that can be you know used that will you know, there's a mechanism by which you you transect it But it's a little bit small for the graphs that we sometimes get so it's not always ideal. So I'll slide Along that, you know, let's go that way for a minute and I'll slide along the Superior surface and and I'll give counter traction and then I feel it cutting okay, so same thing I kind of go up as high as I can almost to the tourniquet or so and then and Then it cuts and that usually gets the superior portion and then I'll do something similar for the inferior portion Just to finish it off Good And so we'll pull the sub cue away from the IT band if we can. So let's see. That's good And so Ben if you're struggling with this portion of the case, you can't get that thing to transect and you're worried about you know Transacting it short you have a low threshold to make another counter incision. Yeah, I think I've done that once or twice but Usually Not not too big of an issue and then you can go back superiorly if you need to So, of course in the demo, we're going to come up short and need to make the incision and transect it. So That's just the way things go so I can feel it's still attached Try to keep pulling the sub cue away from the IT band. Yeah, perfect And sometimes it's that it's transected but it's still kind of attached to vastus fascia Okay, there we go, that'll be the last of it I think You can feel the posterior portion still attached Okay And the knees coming with us a little So the lady finger would be Okay, I should do it Very Stout IT band on this. Yeah, I think it's just elderly attached to our fascia great So that's that and so you can see it sometimes takes a little fatter muscle with it And we'll then tubular eyes it peel a little of the fat off So just take a whip stitch at the end And then the other question is how far distal to take it towards Gertie's again The original description was taking it all the way to Gertie's But what I use as a metric is I just feel the cartilage surface of the lateral femoral condyle So we'll take the other retractor as well And I Don't want it to if when I attach it, I don't want it. Can I get a knife? Perfect? I don't want it to be tethering the Lateral aspect of the patella down, so I'll just peel this down towards Gertie's Until I can feel that now I can feel the condyle and now I know I'm done So I've got a good graph there. You can see this becomes our ALL by attaching here we'll suture it after we pass the schnitt through the capsule right along the posterior aspect the lateral femoral condyle and more distally then it becomes the middle portion is the ACL portion which we then attach to the Anterior aspect of the tibia good, so we'll ask Melissa to whip stitch that while with maybe with an assistant, so We'll take that right angle snap that we had one important thing to note while you're whip stitching the graph is that it's so wide so you really want to work to tubularize it because if it's too thick at the At the most proximal aspect it's gonna be hard to pass through your tunnel And then if we could switch to the other camera while Melissa's whip stitching I'll show the the tibial side of things so on the tibial side the incision or exposure Okay is Yep, so we're gonna move cameras just to show this so I go down to the level of the PEZ and The periosteum above the PEZ towards the level of the growth plate gets Longitudinally incised and then we'll elevate the periosteum, so there's like a little bit of a exposure there So it's basically two to three centimeter exposure Yeah, you can see that and So I've elevated the periosteum TJ. Could I ask you to hold that retractor? Thank you so much And so we'll demonstrate Here's the PEZ right here, so I've just taken maybe the upper one-sixth or so of the pet of the PEZ of the gracilis and elevated it and then here's periosteum And then we'll move up for a minute good hold that if you don't mind And then this is about the level of the physis, and I've just gotten used to knowing when to stop You know I'll use a needle sometimes and push it in or sometimes I'll see the physis and just stay distal to it with this trough so what I do is take a bur or I I can just use the tip of a wooden handle and Decorticate or create this trough, so this is not like where you'd put your tibial tunnel But this is where you're gonna secure the distal end of your graft to the periosteum And so it's three to four whip stitches and of note if we don't get to it later We put a stitch in the periosteum big thick bites as we know in young kids it's going to hold nicely and then we move about you know eight to ten millimeters approximately for the pass through the graft and then back down to eight to ten millimeters to a Corresponding spot on the other side of the periosteum if you should Go into a little bit of the edge of the patella tendon with your needle It's no big deal like there's good tissue there to grab you Just don't want to bugger the tibial apophysis too much with your passes. That's perfect. Thanks so now we'll just show the arthroscopic portion and So with the tibial Trough prepared and with the IT band harvested and prepared now. I'll go take a quick look at the lateral aspect of the knee and and and we'll show this in a second, but but behind the condyle is where the Clamp passes out so So we'll put our water on here, let me know when you're just about ready Melissa. I'm just about ready Do we have a pedal or it's just okay handheld Just right here now a few sort of tips or pearls for The intra articular portion you want to clear out the fat pad enough so you can see the inter meniscal ligament clearly because you're going to Go underneath that to go grab your graft So here's our tibial stump which will clear out But I'll kind of leave about this much stump just as a guide for the footprint and there's our femoral stump And I'll usually leave a little bit as well So here's another important portion so we like the idea that a little soft tissues left at the footprint so that we can kind of slide through it, but leave an inferior kind of hammock or sling to Accommodate our graph going above it so if we left this and our graph went right through here to the aperture I'm going to make in a moment Then this protects the graph from sliding into the lateral compartment I've never had that happen, and I don't always get a perfect hammock or sling especially since we suture So the next step is that long curved Kelly clamp so So what we do is Slide in here, okay, and once again. This is a little bit more medial than normal Okay, so so I might have my normal portal here, and I'm way over Sorry about that, and I'm way over here So that the angle I slide past or medial femoral condyle Into the notch and then I'll just hold the camera if you don't mind for a moment Look up while you do perfect, okay, so then I'll push through this tissue and try to slide around the lateral femoral condyle And I put my finger through the incision of The IT band harvest so that I can feel it popping out at the level of the capsule, and I try to hug the condyle Because of in part because of all of Kevin Shea's great anatomy studies that show Stuff's not too far away so I've now popped through the capsule and perhaps We can get an angle from the other side so we can actually come out arthroscopically for now and Get a look From this side Okay, perfect, so If I look here We're gonna pull Way down and try to get some sort of a section perhaps And So there's our clamp sticking out This is capsule. Okay, so it popped through capsule and then This is the IT band defect. Here's the superior border of that IT band up here. Okay, and so now we'll take The free stitches. Okay, that's on our graph Usually with like a schnitt because sometimes it's a little hard to get back here. We have a great exposure here But sometimes this parts of struggle so I tell if you just try to move a little bit to your right Melissa Perfect. Yeah, so I'll open my curve Kelly clamp now. Let me know when it's open. You've got it Okay, good. So she passes the suture in now some some people I think Phil Wilson Kevin Shea Mike Bush others have taken to kind of going arthroscopically outside in with a spinal needle and making their aperture and passing a Stitch in which makes a lot of sense as well So that's another way to go if this step proves to be a struggle So what I'll now do is put my scope back in and we'll watch our IT band graph enter the joint Okay, here we go, so we're in so I'll turn the water on it'll flow out my lateral portal, but here is My graph and you could see that little hammock or sling below me. So I'll wiggle this out. I've got the stitches And as Melissa said you may want to take some time on taking your time on And As Melissa said you may want to take some time on Tubularizing or bulleting the tip of the graph to make sure It will pass through the capsule. So we're now hold this if you don't mind and we're now Running into just that little roadblock. So we might not have spread quite enough and so we can try a little bit of Extra pulling in a moment. And then if that doesn't work, well, I can spread outside. Hold on one sec If you don't mind holding that again Okay Okay, so it's not coming so we'll we'll spread again, so I'll just follow my pathway in so that curved clamp If you see where that thing went that would be great and then I'll push out again You can also dilate your path from outside in if you can see where it's going into the capsule so I can give a spread here to help them and Then tubularizing and trying to feed that graph through. Did you hold the camera for a moment? Yeah, I just need a counter Okay, so could you help me find that long curve Kelly clamp that I just used for that previous step? yeah, for now, I'll use the So You're getting a good okay So we'll go back to the long one Maybe it's a sling too So we'll spread a little bit more to make sure this tip Yeah, I see All right, so we've bulleted it a little more to see if that's going to help Good. So now we're through so I'm not sure we got that I'm live, but there's a nice big graph. So we provisionally so it slides in and we provisionally place it Into the a.m. Portal though. You could wait with this step So the next steps are we'll go back to the anterior camera or the camera in the front of the knee rather than the lateral side of the knee and show how That same clamp can be used to come up through the incision. Okay, right along that trough we've made and then wiggle slide extra periosteally But below all soft tissue below the intermeniscal ligament. So here I'm going to raise my hand And this I tell the fellows is the third tricky part of the case To get under here. Okay. So there we are Yeah, we'll look from above and you want to try to make sure you're under all the IML intermeniscal ligament Tissue. So now we have to make our trough here. So that's our tibial epiphyseal trough. So we take our rat tail rasp and In the we have one at Boston that we're a little more familiar when the one in this tray Is a little bit it's got two different shapes to it, which is kind of nice in some ways, but it it doesn't Work quite the same way. So this one is curved kind of the opposite way and this would be good for the establishing that so we go back and forth and try to get like a Three to four millimeter trough, which we know there's no chance. We're going to hit physis But the key is actually over the anterior kind of border of the epiphysis So it's important to establish your footprint here But where it really makes a ton of contact is over the front So we've used our rasp and I'll also use a a shaver Which I don't think my partners necessarily kind of do Slid up underneath in that same kind of region So just hold the stitches so we don't hold those on tension so we don't incorporate those We don't seem to have suction working on here, so let me just put that back on If you could give me more suction, that would make this part of the case extremely... Yeah, I think you're doing great on time. Okay, great. You know, if you've got another three or four minutes to kind of wrap up the last pearls that you're doing. Yeah, we should be able to. Perfect. Yep. So still no suction, guys. I think it's been mentioned, the angle of this approach under the inner meniscal can be tricky. Really hugging the bone is important, and sometimes you might come up above the inner meniscal ligament and then just correcting your angle to make sure you come out underneath. That's right. So push in a touch, and I'm going to just go get my stitches. Okay, so there I am under IML again. I'll grab my sutures, and now I'm pulling it out the anterior incision, okay? So I'll get the free ends. Why don't you show right on the footprint? Okay, so there is our graft kind of in between the two limbs of the footprint that I tried to establish. And if we look from the other portal, and so people talk about the non-anatomic aspects of this, but it feels like it sits pretty close to where our normal ACLs sit. We've done an MRI study suggesting the obliquity is a little more shallow, but our 3D motion analysis study looking at kinematics of the knee showed no difference at one year, kind of five years, ten years. So you're not over-constraining like people were concerned, and you're not really having any difference in function compared to the other knee. And I think part of it's like the young body just sort of accommodates to any subtle little differences very quickly because there's not huge tethers or implants or such. So now if we look from the front, we can see our graft. And you saw that I took a pretty long-looking graft, but it just gets below the trough. So TJ, I don't know if you'd be willing to stand here and hold that again. And then Melissa, I'll have you hold that. So the way we secure it here next to our trough is by sutures. So Melissa reminded me. So at this point, we'll secure on the femoral side. And so TJ, could I ask you to hold that and pull down on it? So we've tensioned now. And so if we want to look at our sort of new ALL, I'll take this from you if you don't mind. We'll sponge off a little bit there. So here's our big IT band coming up from Gertie's. And then it wraps around the back of the knee here through that capsular aperture. And so we'll secure it here, and it acts as a lateral tether, lateral. And so I'll try to shoot for two to three stitches here, big figure eights. I pass them through the capsule and some of the periosteum, okay? This is probably around the level of the ALL footprint that's recently been described. And so figure eight, I try to, again, grab some capsule, but not so much that I bunch up the capsule, but such that the graft heals. When you put these stitches in, do you, you are primarily focused on the capsule? Do you pay attention to where you are in relation to the physis? No, I don't think about the physis with this step. Because your stitch isn't deep enough to capture the pericondal ring or the periosteum? I don't believe so. Yeah, so, you know, it's not going through the bone. It's touching the periosteum, grabbing capsule. But we've not, again, we have a really reassuring track record as it relates to growth protection or growth, lack of growth disturbance. And so I'll kind of do one laterally, maybe one posteriorly. And outside this lab, Ben, what position do you recommend the knee be in for this step? So this step, the knee is in flexion, okay? So 70 to 90 degrees. And that's consistent with about sort of half of the studies and study groups out there doing ALL reconstruction. Some seem to think 0 to 30, and some seem to think 70 to 90. And Peter Fabrikant is leading a study from our little ACL study group at HSS, you know, with some of his team that we're a part of that's looking at all the literature. So a systematic review analyzing degrees of flexion and biomechanical and clinical results depending on, or based on, flexion. So looking at like 30 studies, and we haven't seen a difference in outcomes. So I'm not sure we've figured out at what, you know, degrees of flexion we should be tensioning this, but it seems like you might be okay either way. And just neutral rotation of the foot. What about rotation of the tibia? Yeah, and so the original description called for external rotation of the tibia, and we abandoned that out of concern for over-constraint long ago. So just letting the leg hang, and then we'll do sutures to the periosteum in full extension. So when we started doing 30, again, there were some flexion contractures or concern for that, so we sort of moved to 0 degrees, okay? And so I don't think we need to show periosteum stitch going through grafts and then going through periosteum, but, you know, we'll throw three or four of those. So that's our IT band, so if you hold that, we'll look one more time at the graft intrarticularly. And questions? Great. I really appreciate it, Ben and Melissa, and I would really just emphasize that, you know, if you primarily do adult specimens or adult patients, you know, the periosteum, Ben was saying earlier, is quite robust, it feels like leather, so, you know, really this technique utilizes that quite a bit. And you know, I really encourage you guys at your labs, everyone in a red vest is very, very experienced in doing pediatric ACL techniques. The IT band, if you get used to it in the lab, this particular technique can be something that is easily adapted in your own setting. We're just going to do a quick switch of the cadavers. In about 10 minutes, we're going to do Jeff Nepple's technique on all epiphyseal ACL reconstructions. I think at your all-station, you have opportunity to do both of them. And then we're going to finish off the morning with LAT and tibial spine. So about 10 minutes, we'll come back and do an all-epiphyseal ACL.
Video Summary
In this video, Ben Hayward and Melissa Castino demonstrate a surgical technique for ACL reconstruction using the iliotibial band. Ben explains that this is his favorite procedure in orthopedics because it is low-cost and biologic, with no hardware left in the knee. They first approach the lateral aspect of the knee and make an incision from the lateral epicondyle towards the superior border of the IT band. They then harvest a long graft from the IT band, taking care to separate it from the underlying tissues. They secure the graft to the lateral femoral condyle and the tibia using sutures. The video provides a detailed step-by-step demonstration of the procedure and offers tips and tricks for successful execution. It concludes by highlighting the benefits of this technique and its positive outcomes for patients. No credits were mentioned in the video.
Keywords
ACL reconstruction
iliotibial band
surgical technique
orthopedics
low-cost
biologic
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