All-Inside® ACL Reconstruction with ACL TightRope ... - Sumisan SA

All-Inside ® ACL Reconstruction with 

ACL TightRope ® RT and GraftLink 

Surgical Technique 

All-Inside ACL TightRope RT

Introducing the ACL TightRope RT and GraftLink 

Advancing All-Inside ACL Reconstruction in a New Direction 

The ACL TightRope RT and the GraftLink graft preparation technique 

have moved All-Inside ACL Reconstruction forward by facilitating: 

• Strong, adjustable cortical fixation on both tibia and femur 

• Single hamstring harvest, which may reduce morbidity 

• Simplified graft passing and fixation 

• Tensioning from both sides of the graft in any degree of extension 

Semitendinosis Harvesting and GraftLink Preparation 

In most cases only the semitendinosis is needed to create the GraftLink 

construct. For a less invasive option, harvest the tendon using the 

minimally invasive hamstring harvest technique and instruments 

described in technique guide LT0124. 

Minimally Invasive Graft Harvesting Set (AR-1279S)

Set the adjustable workstation posts at a distance apart that is 10 mm less than the desired graft length 

(since the final graft length will be approximately 10 mm longer after tensioning). 

The intraarticular portion of the graft is approximately 30 mm long. Therefore, a total graft length of 

70 mm will provide at least 20 mm in the sockets. 

Note: Depending on desired length, the graft may be wrapped around the posts in two ways: 

Option One 

If a thicker graft is desired and the tendon has sufficient length, use option one. Load ACL TightRopes 

over each strand of the graft and wrap the tendon as shown in the following steps. 

1 

2 

3 

If using a combination of one ACL TightRope and one ACL TR RT, the ACL TightRope RT must 

be placed on the tibial end of the graft. If using two ACL TightRope RTs, the implants may be moved 

to either end of the graft.

4 

Hold the ends of the graft under tension using hemostats. Pass FiberWire ® suture through one side 

of the graft loop. Make sure every limb of the graft is included in the stitch. If the first pass does not 

incorporate all graft limbs, make a second pass on the same side. 

5 

Pass the FiberWire through the other side of the graft loop, again, making sure to incorporate all 

strands of the graft on that side. 

6 

Pass each end of the suture around the graft circumferentially and tie them tightly around the graft. 

7 

Cut off the suture tails and place another stitch in a similar manner on the same end of the graft. 

Repeat the stitching technique on the opposite end of the graft. 

Note: In order to distinguish the femoral end of the graft from the tibial end, TigerWire ® may be used 

to stitch the tibial end of the graft. 

Please turn the page for option two

Option Two 

If a longer graft is desired or the length of the tendon is not long enough for option one, the graft 

may be folded over the posts only two times and sutured in a similar fashion. 

1 

The graft ends are tucked inside the graft loop to facilitate passing. 

2 

Final GraftLink construct. 

Graft Sizing 

Measure the graft length and diameter. Pass both the femoral and tibial ends 

of the graft into the sizing block to measure diameter for socket drilling.

Graft Tensioning 

Remove the graft from the workstation. Remove one post from the workstation and replace it with 

the Tensioning Device. Place one ACL TightRope implant around the post and one around the 

hook of the tensioner. Pull back on the tensioner until 20 lbs. is reached. Lock the tensioner in that 

position on the workstation. Allow the graft to tension approximately 5-10 minutes. 

Note: check the reading on the tensioner and if tension has decreased, reapply tension to 20 lbs. 

Socket Creation 

The length from the end of the femoral socket to the end of the tibial socket should be at least 10 mm longer 

than the graft to ensure that the graft can be tensioned fully. 

Example: 70 mm graft length 

30 mm 

30 mm 

20 mm 

Assuming an intraarticular length of 30 mm, there will be 

approximately 20 mm of graft in the femoral and tibial socket. 

Drill the femur 20 mm deep and the tibia approximately 

30 mm deep to allow an extra 10 mm for tensioning.

Femoral Socket Preparation 

The femoral socket should be created either through the medial portal or from outside/in, using a FlipCutter ® . 

1 2 

For medial portal drilling, use the RetroButton ® Drill Pin II, Transportal ACL Guides and Low Profile Reamers. Note 

intraosseous length from RetroButton Drill Pin II. After socket drilling, pass a suture with the RetroButton Drill Pin II for 

later graft passing. 

3 

Medial Portal Option 

FlipCutter 

Option 

The FlipCutter may also be used to create the femoral socket. 

Note the intraosseous length on the drill sleeve when pushed 

down to bone. 

4 

After “flipcutting”, pass a FiberStick suture through the 

Stepped Drill Sleeve and dock for later graft passing.

Tibial Socket Preparation 

The tibial socket must be created with a FlipCutter 

1 

3 

Drill the FlipCutter into the joint. 

Remove the marking hook. 

Straighten the FlipCutter blade and remove from the 

joint. Pass a TigerStick into the joint and retrieve both 

the tibial TigerStick and the femoral FiberStick out the 

medial portal together with an open Suture Retriever. 

Retrieving both sutures at the same time will help avoid 

tissue interposition that can complicate graft passing. 

Note: A PassPort Button Cannula may also be used in 

the medial portal to prevent tangling. 

2 

Flip the blade and lock into cutting position. Drill on 

forward, with distal traction, to cut the socket. Use the 

rubber ring and 5 mm markings on the FlipCutter to 

measure socket depth (inset). 

4 

Place the passing suture from the femoral ACL TR into 

the femoral FiberStick loop and shuttle it through the 

femur. Pull on the passing suture until the mark on the 

implant, equal to the intraosseous length, enters the 

femoral socket, signaling the button has exited the 

cortex. Pull back on the graft to confirm button fixation. 

Note: If using the ACL TightRope RT for femoral 

fixation, the white shortening strands are passed out the 

femur also.

5 

Pull on the implant shortening strands to advance the 

graft into the femoral socket. If using the ACL Tight- 

Rope RT for femoral fixation, shortening strands will be 

pulled proximally (a). Note: pull on each suture one at 

a time (approximately 5 cm each pull) to advance the 

graft. Hold countertension on the graft during advancement. 

Only advance the graft into the femur partially 

(10-15 mm). This will allow for fine adjustments after 

the tibial end of the graft is seated. 

7 

Once the button is delivered out the cortex, the blue passing 

suture may be removed. Pull on the white shortening 

strands to advance the graft into the tibia. 

Note: Ensure the button has a clear path to bone as to not 

entrap soft tissue under the button. 

a 

6 

Place the blue passing suture and shortening strands 

from the tibial ACL TR RT into the tibial TigerStick 

and shuttle them through the tibia. Pull on the blue 

passing suture to advance the button through the tibia, 

while keeping slight tension on the white shortening 

strands to avoid bunching. 

The femoral and tibial shortening strands may be tensioned 

until the desired amount of graft has entered the femur 

and tibia. The knee may be extended and tension applied 

to shortening strands until desired tension is obtained on 

the graft. 

Cut the femoral shortening strands with an arthroscopic 

FiberWire cutter. Before cutting the tibial tensioning strands, 

tie a square knot to protect the implant from inadvertent 

damage during cutting. 

Note: It is recommended that both femoral and tibial shortening 

strands are not cut until the knee has been brought 

through a range of motion and stability has been tested.

Ordering Information 

Implants: 

ACL TightRope AR-1588T 

ACL TightRope RT AR-1588RT 

Instruments: 

For FlipCutter Technique: 

RetroConstruction Drill Guide Set AR-1510S 

Stepped Drill Sleeve AR-1204FDS 

FlipCutter, 6 mm AR-1204F-60 

FlipCutter, 6.5 mm AR-1204F-65 













For Medial Portal Technique: 

Transportal ACL Guide (TPG), 4 mm AR-1800-04 





Low Profile Reamer, 5 mm AR-1405LP 



Low Profile Reamer, 7.5 mm AR-1407LP-50 








RetroButton Drill Pin II AR-1595 

Accessories: 

Suture Retriever AR-12540 

Suture Cutter, 4.2 mm, straight AR-12250 

Graft Sizing Block AR-1886 

Graft Prep Station Base AR-2950 

Graft Workstation Adjustable Post AR-1953 

Tensioning Device AR-4002 

Tensioning Device Post AR-4003 

Suture: 

#2 FiberWire, 38" (blue) w/Tapered Needle, 26.5 mm 1/2 circle AR-7200 

0 FiberWire, 38" (blue) w/Tapered Needle, 22.2 mm 1/2 circle AR-7250 

#2 FiberWire, 38” (1 blue, 1 white/black) w/Tapered Needle, 

26.5 mm 1/2 circle AR-7208 

FiberStick, #2 FiberWire, 50" (blue) one end stiffened AR-7209 

TigerStick, #2 TigerWire, 50" (white/black) one end stiffened AR-7209T

This description of technique is provided as an educational tool and clinical aid to assist properly licensed medical professionals 

in the usage of specific Arthrex products. As part of this professional usage, the medical professional must use 

their professional judgment in making any final determinations in product usage and technique. 

In doing so, the medical professional should rely on their own training and experience and should conduct 

a thorough review of pertinent medical literature and the product’s Directions For Use. 

U.S. PATENT NOS. 6,716,234; 7,029,490; 7,147,651 and PATENT PENDING 

©2011, Arthrex Inc. All rights reserved. LT0157A

All-Inside® ACL Reconstruction with ACL TightRope ... - Sumisan SA

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