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 Independent Drilling Outperforms Conventional Transtibial Drilling in ACL Reconstruction AJSM ‘09 NO YES • • • Anatomic Independent Drilling Transtibial Drilling Anterior Translation + Pivot Normal Translation No Pivot

Can Transtibial Drilling Place an Anatomic Tibial & Femoral Tunnels ? Yes, But . . . AJSM ‘08 Compromise ? Femur AM Tibia PL Impractical Starting point

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 Flexible Instruments Outperform Rigid Instruments to Place Anatomic Anterior Cruciate Ligament Femoral Tunnels Without Hyperflexion J Arthro 2011 90 ° 125 °

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 Lateral Portal View Medial 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 extended 90°

Lateral Wall Impingement with AM Drilling Udagawa AJSM ‘14 “Tibial tunnel should be medial as possible” medial lateral impingement

Failure with Anatomic ACL ? It’s the Tibial Tunne! Galdi OJSM ‘16 Wagner ARTH ’13 AM 7 midsubstance tears 5.2% AM fail vs 3.2% TT fail with lateral wall hypertrophy

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