Utilizing a tibial guide that allows for optimal tunnel placement, position the tibial guide appropriately and drill the guide wire. After the graft size has been determined, ream over the guide wire with the corresponding reamer.
After the tibial tunnel has been completed, position a Femoral Aimer transtibially into the over-the–top position. Drill a calibrated guide wire through the Femoral Aimer and the lateral cortex of the femur (Figure 1). Drill over the previously placed guide wire with the 4.5mm ToggleLoc™ drill bit through the lateral cortex of the femur (Figure 2). After the 4.5mm tunnel is drilled, remove the guide wire.
Assess Room for Femoral Tunnel
Pass the ToggleLoc™ depth gauge transtibially into the 4.5mm femoral tunnel and measure the tunnel length from the lateral cortex of the femur to the tunnel exit point in the joint space to ensure that there is sufficient room to drill an adequate length femoral tunnel (Figure 3).
Drill Full Diameter Femoral Tunnel
Re-insert the guide wire into the femoral tunnel and out the skin of the lateral thigh. Select the endoscopic reamer that corresponds with graft diameter and ream to the depth that will allow the desired soft-tissue graft-to-tunnel interface (typically around 30mm). The reamer should not exit the femoral cortex (Figure 4). Clean any debris from the tunnel to ensure smooth graft passage.
Prepare ToggleLoc™ Device
Pass the soft tissue grafts through both loops of the ToggleLoc™ Femoral Fixation Device with ZipLoop™ Technology (Figure 5). Balance the soft tissue grafts in the loops of the implant to
allow equal amounts of the soft tissue on either side of the loop. Use the measurement previously obtained with the ToggleLoc™ depth gauge to mark the loops of the implant to ensure deployment on the lateral cortex. Measure from the distal end of the ToggleLoc™ device toward the loops and mark (Figure 6).
Make a second mark on the graft by measuring the depth of the “graft tunnel” (typically 30mm). This mark will aid in optimal graft positioning later in the procedure (Figure 6).
Thread the passing suture of the ToggleLoc™ Femoral Fixation Device with ZipLoop™ Technology through the eyelet of the guide wire, which should be exiting the tibial tunnel. Make sure the titanium button is in the middle of the ZipLoop™ Sleeve. Pull proximally on the guide wire to pull the passing suture through the tibial tunnel, joint space and femoral tunnel, exiting through the skin (Figure 7).
Insert Implant into Tunnel
Prior to fixation, ensure that the ToggleLoc™ Femoral Fixation Device with ZipLoop™ Technology is oriented laterally, as it will deploy on the femur’s lateral cortex. The “zip suture” should be on the anterior side of the soft-tissue graft prior to graft placement within the femoral tunnel.
Pull the passing suture proximally until the mark on the loops of the ToggleLoc™ device reach the entrance of the femoral tunnel. Position the implant just beyond the the lateral cortex of the femur (Figure 8). Pull on the distal end of the soft tissue grafts to feel the implant catch on the lateral femoral cortex, achieving femoral fixation (Figure 9).
Position Graft in Femoral Tunnel
Ensure the “zip suture” is anterior to the graft and pull distally to draw the graft through the tibial tunnel and into the femoral tunnel. This will shorten the loop of the ToggleLoc™ Femoral Fixation Device with ZipLoop™ Technology and accurately position the soft-tissue graft in the femoral tunnel (Figure 10). Make sure the knot stays in the center of the zip strand. Correct placement is indicated when the mark on the graft enters the femoral tunnel (Figure 11).
Complete ACL Graft Fixation
After graft positioning, retrieve the “zip suture” through the medial portal with a crochet hook or other suture grasping device (Figure 12). Pass the knot of the “zip suture” through the key shaped hole in the Super MaxCutter™ instrument. Advance the Super MaxCutter™ through the medial portal and sever the suture near the entrance of the femoral tunnel in the joint space (Figure 13). Cycle the knee and implant the desired method of tibial fixation (Figure 14).