Flexible Reamers and Anatomic Tunnel Placement Orthopedic Summit - - PowerPoint PPT Presentation

Flexible Reamers – and Anatomic Tunnel Placement

Orthopedic Summit 2017 Mark E. Steiner, MD New England Baptist Hospital Boston

Disclosures

• Royalties

Stryker

• Fellowship Support

Don Joy Mitek Smith & Nephew Con Med

• Research Support

Don Joy Stryker

Transtibial Drilling Can Place Nonanatomic Vertical Grafts

• Transtibial Drilling

Anterior Translation + Pivot Anatomic Independent Drilling Normal Translation No Pivot

NO YES

Independent Drilling Outperforms Conventional Transtibial Drilling in ACL Reconstruction AJSM ‘09

Can Transtibial Drilling Place an Anatomic Tibial & Femoral Tunnels ? Yes, But . . .

Impractical Starting point AJSM ‘08 Tibia PL Femur AM Compromise ?

Transtibial Drilling to place Anatomic Femoral Tunnel Tibial or Femoral Tunnel will be compromised

Drilling under Tibial Plateau Failed Vertical Tunnel Conventional Tibial Tunnel Places a Vertical Femoral Tunnel

Failures of ACL Reconstruction

• “Failure” up to 25%
• Technical error in tunnel Placement (most common reason)

Locating an “Anatomic” Femoral Tunnel

• ? Remnants
• Clock face
• Ridges
• Measurements 

J Arthro 2015

Measurements in 90° flexion

Davis J Arthro 2015

FINDING THE ACL WITH MEASUREMENTS KNEE 90° FLEXION

Height 7.2 mm 8.7 mm 9.6 mm Depth 33% 55% 66%

Preferred Approach AM Drilling Anatomic Tunnel But Challenge of Hyperflexion

90° 125°

Flexible Instruments Outperform Rigid Instruments to Place Anatomic Anterior Cruciate Ligament Femoral Tunnels Without Hyperflexion J Arthro 2011

AM Aimer at Height of ACL → Point close to ACL center

• 7 mm offset aimer
• Elevated 8.5 mm

View Pilot Hole from Medial Portal Medial Portal View Lateral Portal View

Aimer Placed Through AM Portal Pin Positioned in Starter Hole

Guidepin Placement

• Pin Exits in safe zone on lateral thigh

Advance Flexible Reamer Over Pin

Nitinol Pin and Reamer Create a Straight Tunnel

Tunnel low at 90° = Tunnel posterior at 20°

V

90° extended

Lateral Wall Impingement with AM Drilling

Udagawa AJSM ‘14

lateral medial

impingement

“Tibial tunnel should be medial as possible”

Failure with Anatomic ACL ?

Galdi OJSM ‘16

AM 7 midsubstance tears with lateral wall hypertrophy

Wagner ARTH ’13

5.2% AM fail vs 3.2% TT fail

It’s the Tibial Tunne!

Notch Dimensions vary between patients

? Anatomic Tibial Tunnel or Nonimpinging Tibial Tunnel 15 mm

Medial Tibial Tunnel + Anatomic Femoral Tunnel = No Roof or Lateral Wall Impingement

Anatomic Nonimpinging Graft

Keep It Anatomic Old

Thank you