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Offset guide, nitinol wire, and flexible reamer with eccentric cutting flutes (VersiTomic Flexible Reaming System; Stryker).
Source publication
Anatomic reconstruction of the anterior cruciate ligament (ACL) has been shown to improve stability of the knee, particularly rotational stability, potentially leading to superior clinical outcomes and a shorter return to sport. Nonanatomic ACL reconstruction has been linked to graft failure and abnormal cartilage loading thought to contribute to p...
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Citations
... A flexible reamer system was developed to overcome the limitation of the transportal technique that uses the existing rigid reamer system. Because the femoral drilling in this system is performed without more than 120° of knee hyperflexion, securing the surgical field, a relatively long femoral tunnel can be generated [10]. This can reduce the incidence of posterior wall breakage and avoid the risk of peroneal nerve injury. ...
Background and Objectives: The aim of this study is to investigate the femoral tunnel geometry (femoral tunsnel location, femoral graft bending angle, and femoral tunnel length) on three-dimensional (3D) computed tomography (CT) and graft inclination on magnetic resonance imaging (MRI) after anatomic anterior cruciate ligament (ACL) reconstruction using a flexible reamer system. Materials and Methods: A total of 60 patients who underwent anatomical ACL reconstruction (ACLR) using a flexible reamer system were retrospectively reviewed. One day after the ACLR procedure was performed, all patients underwent three-dimensional computed tomography (3D-CT) and magnetic resonance imaging (MRI). The femoral tunnel location, femoral graft bending angle, femoral tunnel length, and graft inclination were assessed. Results: In the 3D-CTs, the femoral tunnel was located at 29.7 ± 4.4% in the posterior to anterior (deep to shallow) direction and at 24.1 ± 5.9% in the proximal to distal (high to low) direction. The mean femoral graft bending angle was 113.9 ± 5.7°, and the mean femoral tunnel length was 35.2 ± 3.1 mm. Posterior wall breakage was observed in five patients (8.3%). In the MRIs, the mean coronal graft inclination was 69.2 ± 4.7°, and the mean sagittal graft inclination was 52.4 ± 4.6°. The results of this study demonstrated that a comparable femoral graft bending angle and longer femoral tunnel length were observed compared with the reported outcomes from previous studies that used the rigid reamer system. Conclusions: ACLR using a flexible reamer system allowed for an anatomic femoral tunnel location and a comparable graft inclination to that of the native ACL. In addition, it achieved a tolerable femoral graft bending angle and femoral tunnel length.
... Anteromedial drilling has the advantages of being a cosmetically conscious method of independent femoral tunnel drilling with shorter operative times than two-incision approaches; however, it has the risks of producing a short femoral tunnel, posterior wall cortical blowout, and iatrogenic injury to lateral soft tissue structures particularly when using a rigid, straight pin. Flexible reaming systems have more recently been introduced as an alternative to the earlier rigid instrumentation and allow for anatomic recreation of the ACL femoral insertion without compromising the optimal tunnel trajectory and lessens the need for hyperflexion of the knee [49]. The use of flexible instruments without hyperflexion in anteromedial drilling has shown superior ability to produce anatomic femoral tunnels, which are longer and farther from the posterior femoral cortex than those produced with a rigid pin [50,51]. ...
Anterior cruciate ligament (ACL) reconstruction techniques have continued to evolve as our understanding of knee kinematics and ligamentous anatomy has developed. The major femoral tunnel placement techniques include over-the-top, outside-in, transtibial, anteromedial portal with rigid and flexible reaming, and retrograde reaming. Accurate tunnel placement can be achieved with any of the major drilling techniques (outside-in, transtibial, and anteromedial). Advances in technology have revolutionized our methods of practice and changed the way that we approach reconstructive surgery. Superior technology, such as flexible instruments and retrograde reamers, has enabled more accurate drilling of femoral bone tunnels within the ACL femoral footprint, which provides improved stability and knee kinematics. Long-term clinical and functional outcomes have yet to elucidate the preferred method of femoral tunnel drilling; however, there have been excellent short-term outcomes reported using the anatomic femoral tunnel with improved objective and subjective measures when compared to non-anatomic femoral tunnels.
... 29,34,35 As a result, there has been an increased emphasis placed on achieving anatomic positioning of the femoral tunnel over the last decade. 7,10,11,27,33 This emphasis on achieving anatomic tunnel placement has caused many surgeons to abandon transtibial (TT) femoral tunnel drilling in favor of less constrained or "independent" techniques for creating the femoral tunnel, as TT drilling has been repeatedly demonstrated to result in more vertical graft positioning and inferior rotational stability by comparison. 1,3,10,27 Several methods for independent femoral tunnel drilling exist, including the use of a rigid reamer through an accessory anteromedial portal with hyperflexion (AAM-RR) or via an outside-in drilling technique and the use of flexible reaming systems through a standard anteromedial portal (AM-FR). ...
Background
Radiographic and cadaveric studies have suggested that anatomic anterior cruciate ligament reconstruction (ACLR) femoral tunnel drilling with the use of a flexible reaming system through an anteromedial portal (AM-FR) may result in a different graft and femoral tunnel position compared with using a rigid reamer through an accessory anteromedial portal with hyperflexion (AAM-RR). No prior studies have directly compared clinical outcomes between the use of these 2 techniques for femoral tunnel creation during ACLR.
Purpose
To compare revision rates at a minimum of 2 years postoperatively for patients who underwent ACLR with AM-FR versus AAM-RR. The secondary objectives were to compare functional testing and patient-reported outcomes between the cohorts.
Study Design
Cohort study; Level of evidence, 3.
Methods
Included were consecutive patients at a single academic institution between 2013 and 2018 who underwent primary ACLR without additional ligamentous reconstruction. Patients were separated into 2 groups based on the type of anatomic femoral tunnel drilling: AM-FR or AAM-RR. Graft failure, determined by revision ACLR, was assessed with a minimum 2 years of postoperative follow-up. The authors also compared patient-reported outcome scores (International Knee Documentation Committee [IKDC] and Knee injury and Osteoarthritis Outcome Score [KOOS]) and functional performance testing performed at 6 months postoperatively.
Results
A total of 284 (AAM-RR, 232; AM-FR, 52) patients were included. The mean follow-up time was 3.7 ± 1.5 years, with a minimum 2-year follow-up rate of 90%. There was no significant difference in the rate of revision ACLR between the AAM-RR and AM-FR groups (10.8% vs 9.6%, respectively; P = .806). At 6 months postoperatively, there were no significant between-group differences in peak knee extension strength, peak knee flexion strength, limb symmetry indices, or hop testing, as well as no significant differences in IKDC (AAM-RR, 81.1; AM-FR, 78.9; P = .269) or KOOS (AAM-RR, 89.0; AM-FR, 86.7; P = .104).
Conclusion
In this limited study, independent femoral tunnel drilling for ACLR using rigid or flexible reaming systems resulted in comparable rates of revision ACLR at a minimum of 2 years postoperatively, with no significant differences in strength assessments or patient-reported outcomes at 6 months postoperatively.
... Additionally, the relatively recent advent of a flexible reamer system offered another option. This method reduces the required knee hyperflexion during surgery, thereby possibly decreasing the risk of damage of nearby structures during surgery, and therefore, with its curved end, the flexible reamer creates a distinct femoral tunnel in comparison with other techniques [15][16][17]. ...
... Patients who underwent debridement of cartilage injury at the time of surgery had significantly worse follow-up IKDC scores. The use of the flexible reamer system with the anteromedial portal is thought to position the ACL graft in the anatomic position, thus reducing the risk of potential graft failure or the progression of arthritis and decreasing the likelihood of complications associated with rigid reaming systems, including a short femoral tunnel or a potential nerve injury [15,16]. While biomechanical studies have shown some advantages in the creation of a femoral tunnel through the transtibial tunnel [25], the anteromedial portal is believed to produce a more consistent tunnel position [26]. ...
Purpose
To evaluate whether graft-type and tunnel location in ACL reconstruction impact patient-reported outcomes in individuals over the age of 45.
Methods
From 2015 to 2018, patients over 45 years old undergoing primary ACL reconstruction without multi-ligamentous injuries were enrolled in an institutional registry. Baseline International Knee Documentation Committee (IKDC) subjective scores, Knee Injury and Osteoarthritis Outcome Scores (KOOS), Marx Activity Scale, and patient characteristics were collected. Follow-up occurred at a minimum of two years to obtain patient-reported outcomes.
Results
Of the 51 patients who qualified for the study, 44 (86.3%) patients were available at a minimum of two years after surgery date (range 24–60 months). Average age at time of surgery of the available patients was 51.6 ± 4.87 (range 45–66). Between femoral tunnel drilling methods, there were no differences in the proportion of patients achieving clinically significant improvement or post-operative outcome scores. While patients who received patellar tendon autografts were more likely to achieve clinically significant improvement in the KOOS sports subscale, there were no other differences in outcomes measures between graft types. Two patients had a retear of their graft, and an additional five patients complained of subjective instability.
Conclusions
In patients over the age of 45, neither the method used to create the femoral tunnel nor the graft type used in ACL reconstruction caused a significant difference in post-operative PROMs with a minimum of two years of follow-up.
Level of Evidence
Therapeutic IV, Case Series.
... 12,21,26,29,34 Over the past decade, there has been an increased emphasis placed upon achieving an anatomic reconstruction of the ACL in order to more accurately restore native knee kinematics. 7,12,14,33,36 This focus on anatomic reconstruction of the ACL has led to many surgeons transitioning from transtibial (TT) femoral tunnel drilling to other less-constrained, or "independent," methods of creating the femoral tunnel, as TT drilling has been shown to result in nonanatomic, vertical graft positioning and poorer rotational stability by comparison. 1,3,12,33 Several other, less-constrained methods exist to create the femoral tunnel, including the use of an anteromedial (AM) portal, outside-in technique, and outside-in retrograde drilling technique. ...
Background
Recent studies have suggested that femoral tunnel drilling during anterior cruciate ligament (ACL) reconstruction (ACLR) with the use of a flexible reaming system through a standard anteromedial portal (AM-FR) may result in a different tunnel geometry compared with a rigid reamer through an accessory anteromedial portal with hyperflexion (AM-RR).
Purpose
To summarize radiologic, anatomic, and clinical outcomes from available studies that directly compared the use of AM-FR versus AM-RR for independent femoral tunnel creation during ACLR.
Study Design
Systematic review; Level of evidence, 4.
Methods
A literature search was performed using the MEDLINE (PubMed) and Web of Science databases to identify all studies that directly compared radiologic, anatomic, and clinical outcomes between the use of AM-FR and AM-RR. The literature search, data recording, and methodological quality assessment was performed by 2 independent reviewers. The outcomes analyzed included resultant ACL graft positioning and graft bending angle; femoral tunnel positioning, aperture morphology, length, and widening; posterior wall breakage; and distance from various posterolateral knee structures.
Results
A total of 13 studies met the eligibility criteria for inclusion. There was no difference in femoral tunnel aperture location between techniques. There were conflicting findings among studies regarding which technique resulted in a more acute graft bending angle. One study reported greater femoral tunnel widening upon follow-up with the use of AM-FR. AM-FR produced longer and more anteverted femoral tunnels than did AM-RR. The difference in tunnel length was significant and more prominent in lesser degrees of knee flexion. With AM-FR, femoral tunnels were farther from the lateral collateral ligament and peroneal nerve, and 1 of 5 studies had fewer reports of posterior wall breakage. There has been no literature comparing the clinical or functional outcomes of these techniques.
Conclusion
Although no clinical studies exist comparing AM-FR and AM-RR for femoral tunnel creation during ACLR, both systems allow for reproducible positioning of an anatomic femoral tunnel aperture. The use of AM-FR results in longer and more anteverted femoral tunnels than using AM-RR, with exit points on the lateral femur that are different but safe. Surgeons should be aware of the technical differences with each method; however, further study is needed to identify any clinically important difference that results.
... The curved guide was advanced through the AM portal and positioned on the marked location. The primary advantage of these instruments is that they allow for recreation of the ACL footprint while optimizing tunnel length and avoiding the need for hyperflexion of the knee [9,10]. The previous techniques describe placing the curved endoscopic femoral guide in the middle of the femoral footprint at 45°below the horizontal access, resulting in a superolateral trajectory. ...
... The previous techniques describe placing the curved endoscopic femoral guide in the middle of the femoral footprint at 45°below the horizontal access, resulting in a superolateral trajectory. This trajectory crosses the femoral growth plate and results in an exit point along the anterolateral thigh [9]. In the current technique, the guide was positioned to achieve an inferolateral trajectory (Figures 3 and 4). ...
... In adults, flexible instrumentation has been shown to create more anatomic and longer femoral tunnels that are further away from the posterior cortex compared to rigid drilling systems [23,24]. Additionally, these results can all be obtained at lower knee flexion angles with curved instruments, making this stage of the procedure less technically demanding with less risk of complications [9,10]. Rigid reamers have been shown to create horizontal tunnels with higher tunnel acuity, which may influence contact pressure between the graft and the tunnel aperture [25]. ...
Case:
A 13-year-old skeletally immature female presenting with an anterior cruciate ligament (ACL) rupture after a noncontact injury was treated with an intraepiphyseal ACL reconstruction. Flexible instrumentation was utilized to drill a femoral tunnel with an anatomic starting point, with a trajectory that curved inferolaterally away from the physis. At three years postoperatively, she had returned to her preinjury functioning and did not display any lower limb length growth abnormalities.
Conclusions:
The novel application of curved guides and flexible instruments, with intraoperative fluoroscopy, facilitated growth plate avoidance and a successful outcome of ACL reconstruction in a skeletally immature patient.
... The center of the femoral tunnel was marked with a curved awl (Fig. 1b). While visualizing through the AL portal, a 45° curved drill guide was introduced through the AM portal and positioned at the center of femoral tunnel with superolateral trajectory, ensuring adequate tunnel length and avoiding injury to the common peroneal nerve (Fig. 2a) [18]. A flexible guide pin was then inserted through the curved drill guide and advanced through the femoral condyle until it exited the distal thigh. ...
Introduction:
A flexible reamer system (FRS) for transportal anterior cruciate ligament reconstruction (ACLR) has been developed to overcome the technical challenges of a rigid reamer system. The purpose of this study was to investigate the safety and effectiveness of the two-portal technique using an FRS by evaluating femoral tunnel geometry.
Methods:
This study included 30 patients (mean age 30 ± 12.1) who underwent transportal single-bundle ACLR. Operations were performed with the two-portal technique using an FRS. Three-dimensional computed tomography was performed for all patients 2 days after the operation. The femoral tunnel position, femoral graft bending angle, femoral tunnel length, and posterior wall breakage were evaluated. These radiologic outcomes were compared to previous literature-reported outcomes.
Results:
The mean distances (measured as a percentage) from the posterior wall and the intercondylar notch roof to the femoral tunnel center were 29.6 ± 5.5% and 20.1 ± 6.7%, respectively. The femoral graft bending angle (108.4° ± 6.9°) was similar to that associated with the traditional transportal technique using a rigid reamer system, but it was less acute than that associated with the three-portal technique using an FRS. The femoral tunnel length (32.8 ± 4.5 mm) was also similar to the results of the traditional transportal technique using a rigid reamer system, but it was shorter than that of three-portal technique using an FRS. The prevalence of posterior wall breakage was as low as the reported outcomes of the outside-in technique (2 cases, 6.6%).
Conclusions:
The two-portal technique for transportal ACLR using an FRS can achieve comparable femoral graft bending angle and femoral tunnel length compared with the conventional three-portal technique using the rigid reamer system and had a low risk of posterior wall breakage. Therefore, the two-portal technique using the FRS can be considered a safe and effective method for transportal ACLR.
Level of evidence:
Retrospective case series; level of evidence, 4.
... One proposed advantage of a flexible reaming system is that it allows tunnel drilling in much less flexion [5,33]. These systems can be used with the knee flexed only to 100-110°, providing much better visualisation and an option in knees where hyperflexion cannot be achieved due to body habitus or muscularity [3,5,24,29,33]. ...
... One proposed advantage of a flexible reaming system is that it allows tunnel drilling in much less flexion [5,33]. These systems can be used with the knee flexed only to 100-110°, providing much better visualisation and an option in knees where hyperflexion cannot be achieved due to body habitus or muscularity [3,5,24,29,33]. However, limited clinical information about these systems is published. ...
... For cases using the flexible system, the knee was flexed to 100° (goniometer assessment based on skin markings) and the tunnel created using a curved guide and flexible guidewire, flexible 4.5 mm drill and appropriate flexible acorn reamer. Figure 1 illustrates the flexible reaming system used [5]. ...
Purpose
The hyperflexion required for femoral tunnel drilling in anterior cruciate ligament reconstruction can be challenging in patients with increased body habitus or musculature. Whilst allowing femoral tunnel creation without hyperflexion, additional benefits of flexible reamers have been proposed in terms of tunnel dimensions. The purpose of this study was to examine whether these theoretical benefits are seen in a clinical study.
Methods
Fifty adult patients (with isolated anterior cruciate ligament rupture) were randomised to reconstruction with either flexible or rigid femoral reamers. Femoral tunnel drilling was performed at 100° flexion (flexible system) or maximal hyperflexion (rigid system). Otherwise, the procedure was standardised. Femoral tunnel measurements were performed by a consultant musculoskeletal radiologist who was blinded to the method of femoral drilling. Tunnel position, length and angles (axial and coronal) were measured alongside aperture shape and exit point using three-dimensional computed tomography 3–6 months post-operatively.
Results
With no difference in tunnel position, tunnel length was found to increase with the use of the flexible system (37.8 ± 3.7 vs 35.0 ± 4.4 mm; p = 0.024). In addition, the exit point and fixation device were more anterior on the lateral femur using the flexible reamers (p = 0.016). No difference was seen in either tunnel angles or aperture shape. One case of incomplete posterior blow-out was seen in each of the study groups.
Conclusions
This comparative study shows that flexible reamers can reproduce a desired femoral tunnel position with only small improvements of no clinical relevance. As this can be achieved without hyperflexing the knee, these systems can be used for all patients (even when hyperflexion is a challenge).
Level of evidence
I.
... (7)(8)(9)(10) Several commercially available flexible reamer systems have been developed permitting drilling of an anatomically placed femoral tunnel closer to 90° of knee flexion, resulting in longer tunnel lengths and safer distances from the common peroneal nerve. (11,12) Achieving anatomic femoral tunnel placement and subsequent graft insertion demands adequate visualization of the intercondylar notch wall of the lateral femoral condyle. Osaki et al examined the femoral tunnel aperture within the intercondylar notch and demonstrated a discrepancies of up to 5 mm using an outside-in drilling technique and 4.2 mm with a trans-portal drilling technique between tunnel lengths measured at the center versus the shortest aspects of the femoral tunnel aperture. ...
PurposeTo purpose of this study was to compare arthroscopic anterior cruciate ligament (ACL) reconstruction femoral tunnel length measurements from the anterolateral portal between the standard notch view using a 30° arthroscope versus a “top-down” view utilizing a 70° arthroscope to visual the far side of the femoral tunnel aperture.Methods
Arthroscopic femoral tunnel length measurements using calibrated reamers from the standard notch versus the “top-down” view were obtained and reviewed in 54 skeletally mature patients undergoing ACL reconstruction with no prior bony knee surgery. Patient age, height, weight, sex, and surgery laterality were also recorded. Measurements of femoral tunnel length were repeated using both views for inter-observer and intra-observer correlation.ResultsInter-observer and intra-observer intra-class correlation coefficients for the standard notch view and “top-down” views were excellent, with higher reliability values appreciated using the “top down” view. Mean overall femoral tunnel length measurements obtained using the standard notch view were significantly longer than measurements from the “top-down” view (p < 0.001).Conclusions
The standard notch view provides significantly longer femoral tunnel length measurements in comparison to the “top-down” view.
... Flexible reamer systems allow an additional way of uncoupling the tibial and femoral tunnels to clearly visualize and establish an anatomic starting point within the femoral footprint of the native ACL while avoiding the complications associated with knee hyperflexion and straight reamers with the far anteromedial portal. 11 Although the literature is replete with ACL failures due to tunnel malposition, the reader should recognize that these data are becoming more obsolete with updated surgical techniques that allow anatomic tunnel placement. New information regarding ACLR failures in the setting of proper tunnel positions using accessory medial or double bundle reconstructions will need to be further investigated. ...
Failed anterior cruciate ligament (ACL) reconstruction is a challenging clinical entity and revision ACL reconstruction is a technically challenging procedure. This article reviews the etiology of ACL failures, the need for appropriate examination and imaging studies, and discusses the technical considerations to allow for a successful revision reconstruction. Furthermore, we elaborate on the decision-making process of when a 2-stage revision is preferred to a single-stage revision.
