All-Inside Technique for ACL-Reconstruction using a FlipCutter® and the TightRope® System.

There have been many innovations in the field of ACL-reconstruction over the years, including the FlipCutter® and TightRope® system (both from Arthrex Inc.). The FlipCutter® is a combined guide pin and reamer that allows minimally invasive socket-creation from the inside out, especially in difficult-to-reach areas. The TightRope® is a further development of the well-known Endobutton™ (Smith & Nephew plc) that consists of a four-point knotless locking system. Its main advantage is its adjustability, which makes it possible to fill the entire bone socket with the graft without any empty space. The all-inside technique using a FlipCutter® and TightRope® offers several advantages: 1. No additional accessory portals and no hyperflexion of the knee are necessary during creation of the femoral canal. Using the FlipCutter®, which is a "retro drill," an outside-in technique is applied. This avoids the problems that arise when using the anteromedial portal for creation of the femoral canal. 2. The thickness of the femoral wall can be accurately measured before drilling. 3. There is no empty space in the femoral canal. 4. Only one tendon is needed. Usually only the semitendinosus tendon is used. 5. There is no need for a tibial canal through the cortex. The procedure starts with diagnostic knee arthroscopy to confirm the ACL-tear and to address any possible additional meniscal or cartilaginous lesions. Graft harvest and preparation (usually only the semitendinosus tendon is needed) is then performed. Next, the knee is prepared by creation of a femoral canal: after the entry point of the femoral canal is localized, while viewing through the medial portal with the knee held at 90° of flexion, the femoral canal is created using the appropriate femoral guide and a FlipCutter®. The tibial canal is then created using the tibial guide and a FlipCutter®. Finally, the graft is passed through the medial portal to the femoral socket and stabilized with the TightRope®. The tibial end is passed through the tibial canal and stabilized with a TightRope® ABS Button. In summary, this all inside technique for ACL- Reconstruction using FlipCutter® and TightRope® offers several advantages over traditional techniques, including no need for hyperflexion or an additional accessory medial portal while creating the femoral socket, accurate measurement of the whole thickness of the femoral condyle before drilling, the possibility of minor changes according to the desired femoral canal length, the ability to achieve no empty space in the femoral canal between the graft and bony canal, and the need for only one tendon (semitendinosus). Additionally, with this technique, the surgeon can easily place isometric sockets in the femur and tibia.