Aesculap® POSITION ACL

The anterior cruciate ligament reconstruction system

Operating technique

Aesculap Orthopaedics
2
Table of contents

POSITION ACL
Anterior cruciate ligament reconstruction system 4

Operating technique
1 | Transplant selection 6
2 | Transplant harvesting 8
3 | Drill channels 10
4 | Transplant preparation 15
5 | Transplant insertion and fixation 24
6 | Double Bundle Technique 27
7 | Postoperative Care 31

Implants 40

Basic instrument set

Femoral aiming devices 43
Tibial aiming devices 44
Instruments 45

Basic Instrument Set

Suture Board 46
Drills 47

Instruments
Dilators 48
Instruments 49

Storage
Additional instruments 50
Recommended Containers 51

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POSITION ACL – anterior cruciate ligament reconstruction system

POSITION is a system for minimally invasive arthro-

scopic anterior cruciate ligament reconstruction.
FR507M The surgical procedure allows for free selection of the
transplant.
With the POSITION Basic Instrument Set, positioning
of drill channels and fixation of the transplant are
performed without a femoral incision.
The POSITION Suture Board facilitates and supports
the transplant preparation.

The freedom of selection of the transplant together

with the special POSITION titanium implants – the
Suture Plate (femoral) and Suture Disk (tibial) – repre-
FO010R sent an important advance compared to fixation de-
vices such as intra- or extra-articular screws or staples.
With correct assemply, transplant, fixation at a dis-
tance from the joint obtains the same results as fixa-
tion close to the joint. Fixation at a distance from the
joint also significantly facilitates any later revision.

The POSITION Implantation Set also makes the opera-

tion easier. It contains all necessary implants and
suture materials for this operating technique. These
are perfectly matched to one another – and are simply
FO029
presented in a single sterile pack – for optimum
results with much less effort.

4
POSITION Suture Plate
Femoral transplant fixation

Less invasive – no lateral incision

Easy revisions – no intra-articular implants
Free selection of transplants with high rupture
resistance

Suture Plate Suture Plate mit Endless Loop

POSITION Suture Disk

Tibial transplant fixation

Better transplant integration attributable to the

central position of the tendon in the drill channel.
Less bleeding due to distal covering of the drill
channel.
Implant removal unnecessary, because of the flush
fit of the Suture Disk on the bone surface and knots
recessed in the implant. Defined reproducible
tightening of the transplant with the POSITION
Twister.
An important feature in the double bundle (DB)
technique since each bundle must have a different
transplant tension.

POSITION Implantation Set

Simple sterile setup
All necessary components from one source
Matching suture materials and implants
Suture materials specific for single- and double-
bundle technique

5
Operating technique
1 | Transplant selection
Two innovations have improved the results of ACL re-
construction surgery: the introduction of arthroscopic
operating techniques and targeted, early-functional
postoperative therapy with immediate full extension.
For a long time patellar tendon surgery was considered
the ”gold standard” in ACL surgery. Femoral fixation
with the Suture Plate enables the use of the semi-
tendinosus tendon with a quadruple technique. This
means that the gracilis tendon can be preserved for
the most part. The semitendinosus tendon alone is
Patellar tendon
Advantages
Variable transplant width
Easy preparation
Stable primary fixation
Preservation of active internal rotation
Slow, clinically proven ligamentation
Good long-term results (published)
Weakening of the antagonist
Semitendinosus tendon
Advantages
Smaller skin incision in non-mobile area
No impairment of extensors
No problems associated with kneeling
Good blood supply to the strands
Elasticity similar to healthy cruciate ligament
6
suitable for performing the double bundle technique,
involving the gracilis tendon only if necessary. The
quadriceps tendon is now being increasingly used for
revision transplants.
To assist in the selection of the appropriate transplant,
the advantages and disadvantages of the different
tendon types are listed below.
Disadvantages
Problems from donor site defects
Impairment of the extensors
Approximately 15 % persistent quadriceps function
loss
Anterior knee pain
Problems with kneeling activities
Slow ligamentation with transplant maturation
Very stiff transplant
Increased risk of cyclops syndrome and arthrofibrosis
Risk of patella fracture
Skin incision in mobile areas, tendency for keloid
formation
Drill channels are completely filled out with bone
material, but not with the tendon; synovial fluid can
enter the drill channels and cause cystic expansion
Double bundle technique not possible
Disadvantages
Impairment of active internal rotation
Bleeding from transplant donor site
No published long-term results on
ligamentation and remodelling processes
Longer preparation time
Weakening of the agonist
 Quadriceps tendon
Advantages
Very thick long transplant
Variable transplant widths and lengths
Active internal rotation preserved
Weakening of the antagonist
Proven revision transplant
Scar distortion can be compensated with
the quadriceps muscle
Implantation technique similar to that
of the semitendinosus tendon
The patellar tendon and semitendinosus tendon make
good transplants for the anterior cruciate ligament.
However, the semitendinosus tendon is preferred in
the following cases:
Patients involved in frequent kneeling activities
Patella infera
Morbus Osgood Schlatter disease
Tibial intramedullary nailing
Injury to the patella or patellar tendon
Regarding alternative operating techniques without
lateral incision, the femoral block technique and
central femoral fixation with an interference screw
are very common. For safety reasons, a distance of
1 mm to 2 mm to the posterior bone wall must be
kept to prevent a bone break-through (“blow out”)
caused by the fixation. Therefore, there is a tendency
to apply the drill channels too far towards ventral
when implanting the interference screw.
Disadvantages
Second ventral skin incision necessary
No published long-term results on ligamentation
and remodelling processes
Double bundle technique not possible
Other possible complications:
Damage to the transplant
Screw or bone defect following a revision
Revision often necessitates a two-stage intervention.
Initially, the hole left by the interference screw is
filled out with a corticospongiosa bone chip. The
actual stabilization is carried out in the second step.
The operating technique using the POSITION ACL
Reconstruction System, as described below, takes into
account the above advantages and disadvantages:
free choice of transplant, drilling technique without
lateral incision and extra-articular implants for trans-
plant fixation with easier revision should this become
necessary.
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Operating technique

2 | Transplant harvesting

Semitendinosus tendon (STT)

The skin incision to harvest the semitendinosus ten-

don must be at least 3-4 cm long. It begins medially
close to the end of the tibial tuberosity.

When preparing the subcutaneous tissue, care must

be taken to avoid injury to the aponeurotic sartorius
tendon as this is sometimes only marginally thicker
than the subcutaneous fasciae.
The aponeurosis of the sartorius tendon is located
above the gracilis and semitendinosus tendon. The
gracilis tendon can be palpated as the thicker tendon
of the pes anserinus. The semitendinosus tendon lying
inferiorly is harvested. The gracilis tendon is harvested
only in the event of inadequate transplant quality.

The gracilis tendon is retracted using a Kocher clamp

in order to identify the gracilis tendon and the STT
from proximal. The STT is luxated with a small, 90°-
curved Overholt clamp and armed with a suture.

8
The STT is taken out distally by taking both the perios-
teum and the Sharpey’s fibres up to the tibial crest be-
low the tubercle. This is to obtain an additional length
of approximately 2 cm. Also, the periosteum flap will
improve tendon attachment in the tibial drill hole.

Note
For easier identification, the sartorial fascia, proxi-
mal to the gracilis tendon, can be split for 3 cm to
4 cm along the length of the tendon.

To strip the tendon, the standard procedure is to use a

6 mm Tendon Stripper (FO023R). With thicker tendons,
the Tendon Stripper FO024R, which has an internal
diameter of 7 mm, can be used. Both instruments
have a measuring scale on the shaft, which allows for
monitoring the tendon length already harvested in
the stripping process.
Before stripping begins, it is important to sever the
connections with the medial head of the gastrocne-
mius, the gracilis tendon, and the semimembranosus
tendon with a sharp cut. Otherwise, the tendon strip-
per can slip and destroy the transplant. Harvesting of
the semitendinosus tendon is more manageable if
good muscle relaxation is ensured.
The harvested tendon is usually between 24 cm and
34 cm in length. The gracilis tendon should only be
used in exceptional circumstances (if the tendon length
is less than 24 cm or if the posterolateral bundle does
not meet the minimum 5-mm diameter required), as
this may result in excessive functional impairment of
the pes anserinus.
An additional periosteal flap is grafted from below
the STT donor area. This will later be sutured into the
femoral loop of the transplant.

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Operating technique

3 | Drill channels

Prior to the actual ACL reconstruction, meniscus and

cartilage pathologies are treated arthroscopically, if
necessary. As the second step of the preparation, any
residual scar tissue should be removed from the fossa.
When doing this, as many structures as possible should
be preserved to improve orientation and preserve pro-
prioceptive sensors.

Tibial drill channel

Single bundle techniques
The remaining distal stump of the anterior cruciate
ligament is used as an orientation point for positioning
the tibial drill hole.

Other reference points are:

Distance from posterior cruciate ligament

Medial tibial spina
Anterior horn of the lateral meniscus

Using the Tibial Aiming Device (FR500M), a 2.5-mm

Kirschner wire (LX045S) is inserted. The distance of the
hook of the Tibial Aiming Device from the K-wire exit
point is 5 mm.

With the K-wire in place, the aiming device is removed

and the tibial channel is drilled out step by step, using
a series of cannulated drills (FR515R - FR521R)
according to the measured total transplant thickness.
Drilling in stages allows subtle corrections to the
channel position and reduces thermal damage to the
spongiosa.

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Patellar tendon transplant
Initially, the tibial channel should be applied with a
6-mm trephine in order to obtain a cylinder of spon-
giosa, which can be used to fill the defects left at the
donor site in the patella and tibial tuberosity.
Note
For very long transplants, the drill channel should
not be too vertical, in order to avoid damage to the
Next the channel is drilled open to the required pes anserinus. Such damage would rule out later
thickness, using cannulated drills as described above. revision using the semi-tendinosus tendon.

Femoral channel
Single bundle technique
Position
In the single bundle technique, the femoral drill
channel is positioned using a Femoral Aiming Device
(FO006R, FO007R, FO010R, FO012R, FO013R). The off-
set hook of the aiming devices is set at 3 mm to 7 mm
diameter, depending on the transplant thickness.
e.g. 5 mm
Transtibial introduction of the aiming device should
be avoided, since the target position of the femoral
drill channel on the lateral wall of the fossa (clock
time 10.30 for the right knee, 1.30 for the left) cannot
be reached. If the placement of the tibial drill channel
is too horizontal, a risk is created of damaging the
inner ligament or the cartilage on the medial tibial
head. With anteromedial introduction of the aiming
device, the knee flexion must be between 110° and
120°. It is common for the Hoffa fat pad to slip into
the arthroscopic field during the procedure, making
it necessary to use the skin surface to read the drill
scale.

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Operating technique

3 | Drill channels

Note
In the case of anteromedial drill channel positio-
ning, the femoral drill channel is sometimes very
short. If the transplant thickness is greater than
6 mm, a test channel of the appropriate insertion
depth should be made as a precaution, to prevent
perforation of the opposite cortex with a thicker
drill, which would hinder the application of the
Suture Plate fixation method.

The femoral aiming device is hooked in an appropriate

position on the posterior fossa wall and the drill pin /
pull-out pin (FO025R, FO036R) is inserted until it
perforates the opposite lateral cortex.

Note
As an alternative to step-by-step drilling, dilators
may be used to compress the drill channel. This
helps prevent drilling-related heat necrosis, while
compression of the spongiosa will also contribute
to the tendon healing process.

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Measuring drill depth “B”
Total graft length (e.g. 70 mm)
To determine the drill depth “B”, the length of the
prepared graft needs to be known. This graft is usually Femoral “Af” Intra-articular Tibial “At”
between 6 cm and 8 cm long. 20 mm 24 mm 26 mm

First, the transplant portion inside the femoral drill

channel is determined (length “Af”). This is calculated
from the total transplant length and the individual
intra-articular length set by the surgeon. It is usually
about 22 – 24 mm. In most cases, 20 mm of the graft
is placed in the femoral channel to enable placement
of the longer graft length in the tibial channel.
Exceptions include very long grafts in small knee joints
(22 mm femoral insertion depth) and graft lengths
shorter than 70 mm (18 mm femoral insertion depth).
Intra-articular placement of the suture material,
how-ever, must be avoided.

Example
70 mm (graft length) “B”
– 24 mm (intra-articular length)
= 46 mm
= 20 mm (tendon portion “Af” in femoral channel)
= 26 mm (tendon portion “At” in tibial channel)
"C"
Then drilling depth “B” can be determined, which
requires at least a 10-mm flip radius of the POSITION
10

“Af”
m

Suture Plate to be added to the length of the tendon

m

portion within the femoral channel “Af”.

Example

20 mm (tendon length “Af“in the femoral channel)

+ 10 mm (flip radius)
= 30 mm (minimal drilling depth “B“)

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Operating technique

3 | Drill channels

There must be at least 18 mm of tendon in both

femoral and tibial channels to ensure adequate tendon
ingrowth. When using the patellar tendon, at least the
length of the bone block should be sunk into the drill
channels.

The drilling depth “B” is drilled under arthroscopic con-

trol, using the reamers with scale markings (FO081R –
FO093R), according to the measured transplant thick-
ness. (If visualisation is poor, read the scale on the
skin.)

Completion of the femoral drill channel

The penetration channel, through the opposite lateral

cortex “C”, is applied with a 4.5-mm reamer (F0026R)
in such a way that the Suture Plate can be pulled
through completely. Preferably, to reduce the overall
operation time, the tendon should be prepared and
armed with holding sutures by an additional surgical
team.
Note
To avoid penetration of the lateral cortex, the last
10 mm of the half channel should be drilled by hand,
without motor power.

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4 | Transplant preparation

Preparation and arming of the semitendinosus

tendon

tendon clamps

work surface scales

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Operating technique

4 | Transplant preparation

Preparation of the semitendinosus tendon

After harvesting the transplant, the useful length of

the semitendinosus tendon is measured along the
Suture Board (FO029). A curette or rasp is used to
remove muscle tissue still attached to the proximal
aponeurosis.

When the semitendinosus is used as a single strand,

previous experience has shown that it is too weak for
the long term. It tends to stretch, especially after 2 to
5 years. Thus it is inadequate for cruciate ligament
reconstruction. For this reason at least three strands
of semitendinosus tendon are used today and where
possible four. In the quadriceps technique a minimum
length of 24 mm is required to support a transplant
length of 6 cm. If the useable tendon material is shor-
ter than 24 cm, the triple technique must be used
instead or a gracilis tendon graft must also be added.

For the quadruple M technique, the entire tendon

graft is arranged in an M-shape with four legs of
equal length.

For the triple S technique, the full length of tendon is

arranged in an S-shape with 3 legs of equal length.

Quadruple M Triple S
technique technique

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The graft thickness is measured with the measuring
block (FO038R) and thereby the diameter of the drill
channels can be set. Each end must be measured
separately since the femoral drill channel is often 0.5 –
1.0 mm thinner than the tibial because of the com-
pression procedure used.

Arming the semitendinosus tendon

The POSITION Implantation Set includes the implants

as well as all necessary suture materials for the
operating technique described below.

The tendon grafts sections for the quadruple technique

or the triple technique are clamped under tension in
the detachable atraumatic tendon clamp on the
Suture Board. The free tendon ends are armed, under
light tension, with Premicron®, USP2, HRT 37. 15 mm

When arming the tendon, care must be taken that ap-

proximately 15 mm of each tendon end is held by the
sutures. The loops must be tightened very tightly. The
distance between the loops must be large enough to
allow attachment of the tendon into the bone channel.

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Operating technique

4 | Transplant preparation

The strip of periosteum harvested from the STT donor

site is sutured into the femoral loop of the transplant,
close to the aperture, to block the channel so that an
additional piece of periosteum is present in the femoral
channel. This will improve the ingrowth of the tendon
into the femoral bone channel and help prevent pene-
tration of synovial fluid.

Once the tendon graft has been armed with sutures, it

should be re-measured since its thickness may increase
because of suturing, especially in the tibial channel.

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Pre-tensioning the transplant

Pre-tensioning device, femoral

Suture Plate holder

Ruler for knot length measurement

Suture Disk holder

Pre-tensioning device, tibial

Suture holder

Spring scale

Spring

Slider

The tendon clamps are replaced with the pre-tensioning devices and the implant holders.

19
Operating technique

4 | Transplant preparation

Arming the implants

In the quadruple strand technique, the graft ends are

brought together to form a loop and the Surgical Loop®
or Dagrofil® USP6 is threaded through this and doubled.
This is then fed through the inner two holes of the
Suture Plate so that the ends lie between the graft
and the Suture Plate.

The outer two holes are threaded with two further

sutures (a pull and a flip suture). The pull suture should
be strong enough to resist breaking since it is often
Dagrofil® USP6
very difficult to pull the transplant through to the
bone channel if the compression technique is used.

Dagrofil® USP2

The Suture Plate threaded with sutures is inserted into

the Suture Plate holder. The Surgical Loop® is fixated
with a clamp after pre-tensioning.

The tibial sutures are fed through the two holes of the
Suture Disk, wrapped around the suture holder, and
secured with the mosquito clamp (BH104R).

The required pre-tensioning can be adjusted by press-

ing the spring on the tibial pre-tensioning device and
fixating the slider in the appropriate position. The
tension can be read from the spring scale.

Both tendon types require pre-tensioning of the com-

plete system for about 5 minutes, at a defined tension.
The transplant and the sutures will be stretched and
the knots will settle down.

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Measuring knot length “K”

„G
“(
50
mm
After pre-tensioning of the transplant, the required

)
knot length is measured and fixed.

„K
“(
For knot length “K”, which defines the distance

30
mm
between the Suture Plate and the implant, the total

)
length “G” of the femoral drill channel is measured

„A
using the Depth Probe (FO027R). From this, the

f“
(20
transplant length “Af“ within the femoral channel is

mm
)
subtracted.

Example
50 mm (total length “G“)
– 20 mm (tendon length “Af“ in the femoral drill
channel)
„G“, 50 mm
= 30 mm (knot length “K“)

21
Operating technique

4 | Transplant preparation

The knot length “K” (example: 30 mm) is adjusted on

the ruler of the femoral implant holder of the Suture
Board; the distance is fixed by knotting the Surgical
Loop® under tension. In this case, the reading is not
taken directly from beneath the Suture Plate, but in
relation to a preset zero point.

Suture Plate

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Insertion marking “M”

Before insertion, an entry mark is made on the trans-

plant. This mark indicates, intra-articularly, when the “G“

Suture Plate has been pulled out of the opposite lateral

cortex by a sufficient distance so that it can be flipped.
This prevents the Suture Plate from being pulled too
far into the muscles and during the plate withdrawal “K“
avoids the risk of trapping tissue between the implant

“A
f“
and the bone, which could lead to a loss of cortical

(2
0m
“M
fixation.
“(

m)
30
mm
The position of the transplant marking is determined )
by the length of transplant in the femoral drill channel
(“Af”), plus an extra 10 mm to allow for the Suture
Plate to be turned (flipped) after it has emerged from
the femoral cortex. The insertion mark “M“ corresponds
to the minimum drilling depth “B“.

Example
20 mm (tendon length “Af“)
+10 mm (flip radius) “Af” 10 mm
= 30 mm (marking “M“)

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Operating technique

5 | Transplant insertion and fixation

Inserting the transplant

Single bundle technique

The pull and flip sutures are threaded through the eye
of the pullout pin (FO025R, FO036R).
Note
Alternatively, the eye of the pullout pin can be
armed with a suture loop at the distal end. This will
make it easier to thread the pull and flip sutures.

Since the transtibial approach to the femoral channel is

not an option, direct pulling of the pullout pin through
the tibial and femoral channels is not possible. The
pullout pin therefore must first be introduced through
the anteromedial portal of the arthroscope and the
femoral drill channel, inserted percutaneously, and
pulled through until the suture loop projects from the
channel. A micro-forceps (OG335R) is introduced
through the tibial channel and the suture is guided out
transtibially. Care must be taken that the suture loop is
long enough. The pull and flip sutures are placed in
the suture loop in such a way that the Suture Plate is
vertical when guided by the pull sutures.

The transplant is pulled through until the mark on the

tendon emerges at the exit of the femoral drill channel.

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Femoral fixation

By pulling the flip suture, the Suture Plate is posi-

tioned across the drill hole. The graft is pulled back
into the joint by 10 mm, so that the Suture Plate
rests flat on the femoral cortex.
Next, the graft is pulled distally by the tibial sutures
so that the Suture Plate rests flat on the cortex.
Then the knee is moved through flexion and exten-
sion several times while keeping the graft under
high tension.

Tibial fixation

Prior to tibial fixation, the surface on which the

Suture Disk (FO035T, FO034T) will be supported is
exposed.

Tibial fixation is executed using the Suture Disk.

The transplant is tensioned and the distal sutures
are tied under tension.

The second knot is applied using a knot pusher

(FO028R). This ensures the secure fixation of the first
knot and prevents knot slipping and the consequent
major loss of implant tension.

25
Operating technique

5 | Transplant insertion and fixation

Reducing residual laxicity

The leg is moved through flexion and extension several

times and kept in hyperextension. The transplant will
settle finally in this process and the tibial knotting
will yield slightly. The residual laxicity caused by this
effect is eliminated by twisting the Suture Disk, using
the Twister (FO037R). The tibial sutures are wrung in
this way. While twisting, the twister should be tugged
occasionally to determine whether any residual laxicity
remains. Otherwise, overuse of the twister may lead
to rupture of the tibial sutures. The twister can also
be used to set the transplant tension individually per
strand, while comparing it with the healthy opposite
side. If the single bundle technique is used, this
should be performed at approx. 30° knee flexion.

For this purpose, the twister is hooked into the Suture

Disk openings and the tension is increased gradually,
preferably in steps of clockwise half turns. After each
half turn, the tension is measured by pulling at the
twister handle until the suture disk is lifted off,
slightly, from the tibia. Experience so far shows that
the optimum tension is up to 40 units for female
patients and up to 70 units for males. As a precaution,
the sutures should be cut off only after the final
tension has been achieved.

The Suture Disk “L” (FO034T) with rotation lock reliably

prevents any back-rotation of the implant, thus help-
ing to maintain the applied tension.
The Suture Disk centres the tendon in the tibial drill
channel. To prevent haemorrhages, the channel is near-
ly completely closed towards distal. The knots rest
in the depression of the disk so that the fixation is
supported at bone surface level and the distal implant
does not need to be removed.
With the distal fixation completed, the pull and flip
sutures are removed, the sartorius fascia is closed and
the wound is closed with an intracutaneous suture.
The separated sartorius fascia is sutured to the gracilis
tendon, which displaces the latter in the direction of
the former STT (sartorius reconstruction) and improves
inward rotation.

26
Operating technique

6 | Double Bundle Technique

If preparation of the semitendinosus tendon provides

a tendon graft that is both long enough for the
quadruple technique and also at least 7 mm thick,
the surgeon can switch from the single bundle to
the double bundle technique.

The multi-channel technique allows targeted recon-

struction of the anteromedial and posterolateral
cruciate ligament bundles to produce anatomically
and kinematically correct conditions. Whereas the anteromedial
anteromedial bundle stabilizes the higher degrees
of flexion, the posterolateral bundle becomes taut
at near extension and controls the screw-home
mechanism. Furthermore, the
diagonal course of the posterolateral bundle in the
frontal plane has an additional stabilizing effect on
the periphery, especially on the posterolateral corner
(rotational stabilization).

Using two femoral and tibial drill channels to receive

the transplant substantially increases the contact posterolateral
surface between the tendon transplant and the bone
wall. This improves the blood supply to the tendon
transplant and also leads to increased formation of
“Sharpey’s fibres”, making the graft more resistant
to being torn from the bone.

The elements of the surgical procedure differing from

the single bundle technique are described below.

27
Operating technique

6 | Double Bundle Technique

Anteromedial bundle

In the double bundle technique also as much as

possible of the distal stump of the anterior cruciate
ligament should be retained for orientation purposes.
However, care must be taken in the tibial double
bundle technique to clean the area directly in front
of the posterior cruciate ligament to make the entry
point for the K-wire visible.

1. Tibial drill channel

The Tibial Aiming Device (FR500M) is inserted into the
joint. The target area is the transition from the ventral
third of the insertion to the middle third. The landmark
here is the position of the anterior horn of the lateral
meniscus. One should make sure that the tibial entry
point is only approx. 1 cm from the tibial tuberosity,
to leave space medially for placement of the tibial
posterolateral drill channel.
The K-wire entry is first drilled with the 4.5 mm drill
and then reamed to match the measured transplant
thickness.

2. Femoral drill channel

After the joint has been cleaned, the Femoral Aiming
Device is introduced through the anteromedial portal
and inserted behind the posterior fossa margin in the
11.30 position for the right knee or the 12.30 position
for the left knee. The knee is positioned in 110 – 120°
of flexion and the femoral K-wire is placed so as to
reach both cortices. Then, a pocket hole is formed
with the head reamer according to the femoral graft
diameter. The drill channel is completed using the
4.5 mm drill and the channel length is measured with
the Depth Probe.

28
Posterolateral bundle
posteromedial drill
channel
1. Tibial drill channel
In the subsequent step, the second Tibial Aiming
Device (FR507M for the left knee joint, FR508M for
the right knee joint) is inserted into the previously
drilled anteromedial tibial drill channel, so that the
tip of the aiming device is positioned behind the
dorsal circumference. At 90° knee flexion, the K-wire anteromedial drill
should be visible inside the joint directly in front of channel
the ventral margin of the posterior cruciate ligament
and 3 mm medially from the lateral spina. Here too anteromedial drill
drilling should be performed step by step according channel
to the diameter of the individual grafts.

posteromedial drill
2. Femoral drill channel channel
Because of the very diagonal course of the tibial
drill channel through the tibial head, the Aiming
Device for the posterolateral femoral drill channel
(FO011R) can be positioned easily in the targeted
position dorsal to the right lateral fossa margin, at
the 10.30 position for the right knee and the 1.30
position for the left knee. Care should be taken that
the knee is flexed to 100° (+/- 5°). Here also the
measured drill depth “B” should be drilled according
to the transplant diameter and completed with the
4.5. head reamer. To determine the knot length “K”,
the posterolateral femoral drill channel is also
measured with the Depth Probe (FO027R).

29
Operating technique

6 | Double Bundle Technique

Pulling the two cruciate ligament bundles

through

Both pullout pins are introduced through the antero-

medial access and the suture loops are pulled with a
Micro-Forceps (OG335R) through the corresponding
tibial drill channels. To draw in the two transplants,
first the posterolateral pull-through pin is placed and
then an anteromedial pin. Using a similar sequence,
the transplants are pulled in, first the posterolateral
and then the anteromedial.
The Mini-Suture Disks (FO065T) are used to perform
the tibial fixation. The posterolateral bundle is knotted
at 10° close to the extensor and later tensioned. The
anteromedial bundle is knotted at approx. 45°. During
final tensioning particular care must be taken because
of the small size of suture used – 3 to 4 twists are
fully sufficient to build up tension. Increases in tension
must be very carefully tested to prevent
suture untwisting through the Suture Disk. To prevent
extensor deficits, it is preferable to pretension the
posterolateral bundle close to the extensor cautiously,
applying approx. 20 newtons of force. The anterome-
dial bundle is tensioned to 40 – 50 newtons at 45°
flexion in accordance with the joint play on the
opposite side. It is recommended to use the twister
(FO037R) routinely to determine if any residual
elasticity still remains in the suturing system.

30
Operating technique

7 | Postoperative Care

Long experience in working with experts in the fields The following summarized specific targets may be
of sports medicine (Dr. J. Eichhorn, Sporthopaedi- scheduled to match the particular therapy stages:
cum, Straubing) and physiotherapy (e.g. at the Eden
Rehabilitation Centre, Donaustauf, Bavaria) has
proved the value of phased postoperative treat- Overview of therapy targets, Stages 1–3
ment. Multi-stage therapy respects the physiological
fundamentals (wound healing progress in the Stage Schedule Therapy targets
affected structures), individual conditions, prerequi-
sites for that patient, functional progress in the
activities of daily living (ADL), and the empirical l Postoperative Pain alleviation /
and pragmatic experiences of time- and cost-opti- weeks 1 and 2 reduction
mized rehabilitation. When clinical and functional Reduction of possible
parameters indicate it, the patient can move on to swelling
the next stage. Interindividual differences can be Maintenance of mobility
optimally managed in this way and increased com- in the femoral-patellar joint
plications due to overly ambitious weight-bearing
can be avoided. The following general schedule is ll Postoperative Normalization of
suggested for the respective rehabilitation stages: weeks 3 – 6 mobility
Progressive increase in
weight-bearing to full
functionality
Restoration of coordination
Stage 1 Acute or inflammation stage along with capacity
the start of the proliferation stage – Stabilization of the normal
weeks 1 and 2 on average pelvic-leg axis

Stage 2 Proliferation stage along with the start lll Postoperative Normalization of routine
of the remodelling stage – weeks 3 to week 7 motor functionality
6 on average Achievement of normal
muscle balance along the
Stage 3 Remodelling stage – usually from week 7 entire pelvic-leg axis

31
Operating technique

7 | Postoperative Care

Stage 1

After surgery, the knee joint is first placed in a knee

immobilization splint with Velcro fasteners for a week.
Normally the splint is worn in full extension, and can
be replaced with a 20° splint only if additional sutures
are placed on the posterior horn of the lateral meniscus
or by activation of the medial collateral ligament, and
in these cases, the maximum wear period is 2 weeks.
It has been shown that patients can receive their first
Manual lymph drainage lymph drainage right in the recovery room – the lymph
vessels were compressed by the haemostatic bandage
but can be quickly reopened by massaging the lymph
circulation. This promotes the metabolism in the leg.

On the first postoperative day, the drains are removed

Training the patient in patellar self-mobilization towards distal
and the patient is immediately shown how to perform
patellar mobilization exercises. Otherwise there is a
risk that the small recesses near the patella may
develop adhesions and the patella may become hypo-
mobile, resulting in ventral knee pain. In addition to
the immobilization splint, a CryoCuff (Aircast) for
example can be used, which allows cold water to be
pumped intermittently or continuously around the
knee. Ice packs should be completely avoided in the
postoperative period because the chilling effect is
excessive.

On the first postoperative day also, the patient is

treated with electrostimulation of the vastus medialis
muscle since experience shows that physiotherapy
reaches the vastus medialis muscle only very poorly
in this first stage of therapy.

Particular attention should be given to postoperative

pain therapy since otherwise very severe pain will
cause the operated limb to disconnect from the cere-
bellum, and this can only with difficulty be restored
to a movement pattern through intensive physio-
therapy.

32
On postoperative day 3, a dynamic splint with
unlimited range may be used. This will allow the
patient to direct movement, actively for the most
part, through the non-operated leg to the splint.
Irradiation also helps promote innervation in the
operated leg through the overflow phenomenon.
Heavy emphasis should be placed on proprioceptive
capabilities in Stage 1. The Hanke E-technique is
particularly effective; the immediate postoperative
recall of walking and turning patterns can preserve
neuromuscular connections. Elyth ointment band- Preservation of neuromuscular connections in movement patterns using
ages may be used to reduce oedema and normalize the Hanke E-technique
the postoperative tissue pH.

It is important not to engage in any strenuous

knee-flexion activities during the first two to three
weeks. Furthermore, active stretching of the flexors
should be avoided otherwise the small remaining
attachments of the semitendinosus at the periphery
may tear, resulting in the muscle belly snapping
upwards which hinders the tendon reattachment. In
this first stage of therapy, the patient should start
to engage in half weight-bearing with the aid of
two crutches, concentrating at this point on the
achievement of a very smooth gait pattern during
gait training. Since this stage of therapy is performed
mostly at rest, it must be accompanied by a regimen
of thromboembolic prophylaxis with low molecular
weight heparin and adequate pain medication.

In the second week, lymph drainage is continued.

Furthermore, ointment bandages should be applied,
manual physiotherapy exercises should be started
to improve joint mobility by gentle traction, and
attention should be given especially to mobilizing
the capsule, patella, and menisci.

33
Operating technique

7 | Postoperative Care

By the end of the second week, 0/10/90° mobility

should be achieved. With the aid of a ski boot, for
example, to assist gravity, and by engaging in self-
mobilization and self-traction exercises, patients can
comfortably improve their mobility (flexion) also at
home and ward off the onset of pain and swelling.
There should be a gradual or at least a very noticeable
decrease in swelling. If these goals are reached, the
patient is ready to move to Stage 2.

Auto-mobilization of the kneejoint in extension by using a ski shoe Stage 1 complications

In rare cases, a haematoma may form at the tendon
donor site, which can then manifest on the third or
fourth postoperative day because of sluggish circula-
tion from the short-acting anaesthetic.

Many patients complain of shooting pains and a sensa-

tion of tightness in the operated area of the leg when
they stand up. This is due to the still impaired function-
ing of the lymph and vein pumps – the return circula-
tion of the blood components back to the heart is still
inadequate.

Some patients also report reddening and tension pain

around the tibial tendon anterior compartment, but
this regresses significantly after 8–10 days.

Patients should be clearly instructed that in the event

of fever, throbbing pain or reddening at the knee joint,
they must immediately inform their surgeon since
early detection and immediate initiation of appropriate
treatment are a critical part of joint infection
management.

At this initial stage, the knee joint should only be

punctured in the event of tension pain at rest.

34
Stage 2

The success of the operation is supported postoper-

atively with a FourcePoint brace, which helps soften
the stress of daily living for six weeks. When physio-
therapy exercises are performed, it has to be re-
moved.

The goal of Stage 2, which lasts until the sixth week

after surgery, is the achievement of full mobility
with no effusions or pain in the joint. A follow-up
examination is usually performed after four weeks.
If persistent deficits in rehabilitation are detected at
that point, these should be immediately managed
with targeted physiotherapy programmes. In more
severe cases, about two weeks of inpatient rehabili-
tation may be necessary. The combination there of all
Promotion of proprioceptively guided knee joint stability with single leg
physiotherapy and physical resources nearly always
half-knee flexions on a Posturomed training platform
resolves the problem and in most cases obviates a
recourse to revision operations to improve mobility.

The training exercises in Stage 2 are characterised

by targeted co-contractions with tensioning of the
extensors and flexors. The Posturomed Proprio-Swing
has proved very beneficial in this regard: it allows
the patient to train the neuromuscular connection
by gentle flexion (co-contraction) on a platform
with built-in instability. This is very safe since the
joint is not confronted with angle acceleration when
using this device. At this stage also, the patient can
begin to slowly decrease the use of crutches.

35
Operating technique

7 | Postoperative Care

Intensive medical exercise therapy is still not encour-

aged at this stage; graft stability still depends on the
stability of the primary fixation, and Sharpey’s fibres
– the source of secondary fixation – develop only
slowly over this second stage and until the end of the
sixth week. Cautious medical exercise therapy can be
started therefore towards the end of Stage 2 (weeks
5-6). Active exercises can also be gradually intensified,
especially for the vastus medialis muscle, to eliminate
further need for electrostimulation.

Initiation, enhancement and stabilization of gait patterns on the mini-

trampoline to promote co-activation

The illustration on the left shows an option which can

also be performed at home – appropriate facilitation of
the vastus medialis muscle by generation of isometric
stress with a Theraband while seated. In Stage 2, many
patients can return to work if it does not require
strenuous bodily effort.

Knee extension exercise with abduction stress using the Theraband to

promote facilitation of the vastus medialis muscle

36
If an aquatic exercise pool is available, intensive
exercises can readily be performed because of the
positive hydrostatic pressure of the water and
reduction of body weight. The use of this resource
in particular often produces surprisingly fast and
excellent results. The most common types of exer-
cise equipment for Stage 2 include the exercise
bicycle at the start of the stage and the ellipsoid
trainer (cross-walker) at the end.

Ellipsoid trainer

37
Operating technique

7 | Postoperative Care

Stage 2 complications
In this stage also one should be on the watch for tar-
dive infection manifested by increased swelling, pul-
sating pain, or an excessively warm joint. Furthermore,
should overloading occur – especially in flexor train-
ing – repeated tearing in the area of the ischiocrural
musculature with a loss of function in the semitendi-
nosus muscle may result; the event, however, does
not have any particular functional implications.

Should significant effusion formation still occur

towards the end of the 6–8 week period, a single in-
jection of intra-articular corticosteroid (e.g. Lipotalon)
can be performed, which in most cases will clear up
the hyperreactive tendency. If it does not do so, the
patient should undergo a nuclear magnetic resonance
examination. Scar tissue or the development of a
cyclops syndrome is frequently responsible for the
hyperreactive problem.
If such is the case, appropriate therapeutic measures
should be started, including an investigative arthro-
scopic intervention, if necessary.

Follow-up arthroscopic intervention should also be

considered if by the end of Stage 2 the extensor is
more than 10° impaired or there is a flexor deficit of
more than 20°. Such complications are more easily
managed especially at this early stage.

38
Stage 3

At this point most patients perform self-exercises

under the guidance of a physiotherapist. The first
walks can be on level ground. Exercise bicycle and
cross-walker exercises are intensified. Professional
athletes may now start sport-specific exercises
which are targeted to achieve the muscular quality
required for the specific sport. Emphasis is placed
on improvement in complex coordination ability,
with the use of continuously more challenging
exercises. There is increasing use also of some of
the open kinetic chain exercises for weight-bearing
since these qualities are necessary in most types of
sports. Special attention is given in this stage also
to improving the basic endurance performance of
the athlete through targeted exercises.
Controlled knee half-flexion with varus stress to activate the medial
stabilisers of the knee joint

After five months, an “Ortho check” should be

performed, during which parameters such as endu-
rance, resilience, responsiveness, coordinative ca-
pacity (proprioception), etc. are tested. Any deficits
discovered should be targeted for further treatment Ortho Check© Functional Analysis
so that professional athletic ability is recaptured by
the fifth to seventh month after surgery. Fewer Strength
exercise components are generally prescribed for
recreational athletes and in their case the recapture Resilience Endurance
of athletic ability may take up to 8 months.

Proprioception Clinical status

Biomechanics
Patient pathological deficit
ADL able to do sports

Diagram of results of the Ortho Check

39
Implants

FO030T Suture Plate Sterile,

titanium alloy
4 x 12 mm

POSITION Endless Loop

FO070T, 20 mm
FO071T, 25 mm
FO072T, 30 mm
FO073T, 35 mm
FO074T, 40 mm
FO075T, 45 mm
FO076T, 50 mm

FO035T Suture Disk “S” Sterile,

titanium
Ø 14 mm

FO065T Mini Suture Disk Sterile,

titanium
Ø 11 mm

FO034T Suture Disk “L”

with rotation lock
Titanium
Ø 14 mm

40
 FO039 Implantation set for STT, sterile
comprising:
1 x Suture Plate FO030T
1 x Suture Disk “L” FO034T
4 x Premicron®, USP2, HRT 37, 75 cm
1 x Dagrofil®, USP6, 150 cm
1 x Dagrofil®, USP2, 150 cm
1 x Surgical Loop®, 4 mm, 75 cm

FO040 Implantation set for STT, sterile

comprising:
1 x Suture Plate FO030T
1 x Suture Disk “S” FO035T
4 x Premicron®, USP2, HRT 37, 75 cm
1 x Dagrofil®, USP6, 150 cm
1 x Dagrofil®, USP2, 150 cm
1 x Surgical Loop®, 4 mm, 75 cm

FO042 Implant set for DB-ACL fixation

2 x FO030T Position Suture Plate
2 x FO065T Position Mini Suture Disk
1 x Premicron® USP2 HRT 37 (M) DDP, green, 4 x 75 cm,
REF 0026717
1 x Dagrofil® USP2, white, 1 x 150 mm, REF 0372102
2 x Dagrofil® USP6, green, 1 x 150 mm, REF 0342149
1 x Surgical Loop® 4 mm, green, 1 x 75 mm, REF 1094912

FO043 Implant set for tibial ACL fixation, lock

1 x FO034T Position Suture Disk “L”
1 x Premicron® USP2 HRT 37 (M) DDP, green, 4 x 75 cm,
REF 0026717

41
Implants

FO044 Implant set for tibial ACL fixation, standard

1 x FO035T Position Suture Disk “S”
1 x Premicron® USP2 HRT 37 (M) DDP, green, 4 x 75 cm,
REF 0026717

FO045 Implant set for tibial DB-ACL fixation

2 x FO065T Position Mini Suture Disk
1 x Premicron® USP2 HRT 37 (M) DDP, green, 4 x 75 cm,
REF 0026717

FO046 Implant set for femoral ACL fixation

1 x FO030T Position Suture Plate
1 x Dagrofil® USP2, white, 1 x 150 mm, REF 0372102
2 x Dagrofil® USP6, green, 1 x 150 mm, REF 0342149
1 x Surgical-Loop 4 mm, green, 1 x 75 mm, REF 1094912

42
Basic instrument set

Femoral aiming devices

FO012R Femoral aiming device

3 mm offset

FO013R Femoral aiming device

4 mm offset
off-set

FO010R Femoral aiming device (not illustrated)

5 mm offset

FO006R Femoral aiming device (not illustrated)

6 mm offset

FO007R Femoral aiming device (not illustrated)

7 mm offset

FO011R Femoral aiming device

for posterolateral drill channel in femoral double
bundle technique

43
Basic instrument set

Tibial aiming devices

FR500M Transtibial aiming device

FR507M Tibial aiming device (not illustrated)

for posterolateral drill channel in double bundle
technique, left

FR508M Tibial aiming device

for posterolateral drill channel in double bundle
technique, right

44
Instruments

Tendon strippers
Effective length: 340 mm,
graduated shank

FO023R
Inner diameter 6 mm

FO024R
Inner diameter 7 mm

FO032R Rasp (not illustrated)

FO027R Depth probe

Effective length 300 mm

FO028R Knot pusher

FO014R Notch gauge

FO037R Twister
for FO034T and FO035T

FO067R Mini-Twister (not illustrated)

for FO065T

45
Basic Instrument Set

Suture Board

FO029 Suture Board

– Incl. 2 tissue clamps (FO029850), implant holder,
pretensioning attachments, and
baby mosquito clamp (BH104)
– Modular setup for individual OR procedures
– Reliable recordings and measurement scales for
tendon preparation
– Implant fixation for transplant pre-tensioning

FO031 Suture Board

– Addition to FO029 when using the double bundle
technique

46
Drills

Head reamer
2-wing, cannulated (2.6 mm)

hexagonal shaft, length: 180 mm

FO081R, Ø 5 mm FO088R, Ø 8.5 mm
FO082R, Ø 5.5 mm FO089R, Ø 9 mm
FO083R, Ø 6 mm FO090R, Ø 9.5 mm
FO084R, Ø 6.5 mm FO091R, Ø 10 mm
FO085R, Ø 7 mm FO092R, Ø 10.5 mm
FO086R, Ø 7.5 mm FO093R, Ø 11 mm
FO087R, Ø 8 mm

hexagonal shaft, cannulated

length: 205 mm

FO079R, Ø 4.5 mm

hexagonal shaft, not cannulated

length: 205 mm

FO078R, Ø 4.5 mm

Drill, tibial
cannulated (2.6 mm)

hexagonal shaft, length: 160 mm

FR541R, Ø 5 mm FR548R, Ø 8.5 mm
FR542R, Ø 5.5 mm FR549R, Ø 9 mm
FR543R, Ø 6 mm FR550R, Ø 9.5 mm
FR544R, Ø 6.5 mm FR551R, Ø 10 mm
FR545R, Ø 7 mm FR552R, Ø 10.5 mm
FR546R, Ø 7.5 mm FR553R, Ø 11 mm
FR547R, Ø 8 mm

Tissue protection sleeves (not illustrated)

e.g. for determining transplant thickness
Inner diam. / Ø

FR705S, Ø 5.5 mm FR708S, Ø 8.5 mm

FR576S, Ø 6 mm FR579S, Ø 9 mm
FR706S, Ø 6.5 mm FR709S, Ø 9.5 mm
FR577S, Ø 7 mm FR580S, Ø 10 mm
FR707S, Ø 7.5 mm FR710S, Ø 10.5 mm
FR578S, Ø 8 mm FR581S, Ø 11 mm

47
Instruments

Dilators

FR750 Drill channel dilator set

comprising:
FR751R Storage tray
FR752R Handle with extraction hammer
FR775R – FR781R Dilators, sharp
FR785R – FR790R Dilators, sharp
(round dilators must be ordered separately)
FR793R – FR795R Tibial guide pins
FR753R Femoral guide pin

FR751R Storage tray for dilators (not illustrated)

FR752R Handle with extraction hammer

Dilators, sharp

FR775R, Ø 5 mm FR785R, Ø 5.5 mm

FR776R, Ø 6 mm FR786R, Ø 6.5 mm
FR777R, Ø 7 mm FR787R, Ø 7.5 mm
FR778R, Ø 8 mm FR788R, Ø 8.5 mm
FR779R, Ø 9 mm FR789R, Ø 9.5 mm
FR780R, Ø 10 mm FR790R, Ø 10.5 mm
FR781R, Ø 11 mm

Dilatatoren, stumpf

FR755R, Ø 5 mm FR765R, Ø 5.5 mm

FR756R, Ø 6 mm FR766R, Ø 6.5 mm
FR757R, Ø 7 mm FR767R, Ø 7.5 mm
FR758R, Ø 8 mm FR768R, Ø 8.5 mm
FR759R, Ø 9 mm FR769R, Ø 9.5 mm
FR760R, Ø 10 mm FR770R, Ø 10.5 mm
FR761R, Ø 11 mm

Tibial guide pins, movable head

FR793R, Ø 4.5 mm
FR794R, Ø 6 mm
FR795R, Ø 8 mm

Femoral guide pin, fixed head

FR573R, Ø 4.5 mm

48
Instruments

FO038R Measuring block

For measuring the transplant thickness

K-wires

FO025R
Drill and pullout pin with drill helix and eye,
Total length: 380 mm, shaft: Ø 2.4 mm
Tip: Ø 2.7 mm

FO036R
Drill and pullout pin with eye
Total length: 380 mm , Ø 2.5 mm

LX045S
K-wire
Total length: 310 mm, Ø 2.5 mm

FO002R ACL Basic Instrument Storage Case

– POSITION open basket with storage for Suture

Board FO029 ensuring reliable, gentle and rapid
storage and preparation of instruments

– comprising:
JF222R Open Basket
FO002/200 silicone storage insert for POSITION

FO003R ACL Basic Instrument Storage Case

– POSITION open basket with storage for implants

and instruments

– comprising:
JF222R Open Basket
FO003/200 silicone storage insert for POSITION

49
Storage

Additional instruments

OG335R Micro forceps

Straight, 5 x 1 mm

BM016R Durogrip Crile Wood needle holder

145 mm

50
Recommended Containers

JK440 container

– 1 tray
– Outer dimensions: 592 x 274 x 90 mm
e.g. for storing FR751R (dilators)

JK442 container (no illustration)

– 2 trays
– Outer dimensions: 592 x 274 x 135 mm
e.g. for storing FO002R and FO003R
(ACL Basic Instruments)

JP001 PrimeLine Container Cover, red

– 1 cover, available in several colours

– For JK440 or JK442, red

JG785B Label, red

– Accepts up to 13 characters
– 4 labels per container recommended

JF436R Optiktray

– Optiktray for reliable storage during transport,

cleaning and sterilization of arthroscopes,
e.g. PE545A
– Shaft diameters from 2.7 mm
– Shaft lengths from 140 mm to 200 mm
– Dimensions: 273 x 84 x 41 mm

51
 The main product mark ’Aesculap’ is a
registered mark of Aesculap AG.

Subject to technical changes. All rights reserved.

This brochure may only be used for the exclusive
Aesculap AG | Am Aesculap-Platz | 78532 Tuttlingen | Germany purpose of obtaining information about our
products. Reproduction in any form partial or
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Aesculap – a B. Braun company Brochure No. O13602 1010/1/4