ACL Inside out 4ST (PULLUP®)                            Courtesy of Dr. Philippe Golombert



1.  Prepare the GraftTech® preparation station

Place and secure the Pullup® and Pullup® XL devices on the GraftTech® pre-paration station by applying moderate tension on the white braids loops.



2. Harvest the ST graft


Harvest the ST graft with a stripper. Clean the graft and thin out the end by reducing the enthesis with scissors to obtain a homogeneous graft diameter.


3 Graft preparation with the GraftTech®

Fold the tendon in 4 through the Pul-lup® and Pullup® XL loops.

Block the first turn with a fi gure-of-eight stitch for optimal graft loading.

Warning: be very careful when passing the needle to stay 1 to 2 mm away from the Pullup® loop to avoid damaging it.



Stitch up the graft along its full length: this will give it a homogeneous shape, increase its strength, and avoid intra-articular fl uid from getting between the fi ber bundles.

Calibrate the graft.

Place the graft under slight manual tension and keep it covered with a sterile moist swab.



4 Drilling the tunnels

Drilling the open tibial tunnel

Place the tibial aiming device, followed by the guide pin sleeve.

Drill at 4.5 mm, then drill to match the graft diameter.

 

Drilling the blind femoral tunnel

Place the guide pin sleeve.

Drill at 4.5 mm, then drill to match the graft diameter over a distance of 20 mm.



5 (A) Implanting the construct

Apply traction to the graft

Pass all the sutures by pulling on the shuttle relay suture from the tibia towards the femur. 

Pull fi rmly to avoid damaging the graft, until the plate exits on the femoral end.

5 (B)

Flip the implant

Flip the plate by pulling on the green suture.



5 (C)

Femoral fi xation

Alternately pull on the white PULLUP® braid sutures until the plate is fi rmly placed against the cortex.



5 (D)

Tibial fixation

With the knee fl exed to 90 degrees, insert a spacer in the tibial tunnel to ensure proper plate positioning. Tension the graft by pulling on the white braid sutures until the Pullup® plate is pressed fi rmly against the femoral cortex.

Next, moderately tighten the tibial plate. 



5 (E)

Final tensioning and cutting off the threads

 

Cycle the knee 5 to 6 times with full fl exion-extension cycles, tension the plates for the last time by pulling on the braid sutures the knee being in full extension.

Remove the traction threads and cut off both femoral and tibial braid sutures 2-3 mm away from the plates.